Hang In There, Men header
I’m sure many of you are wondering if maybe this image shouldn’t have been featured in last month’s offerings since you might well be questioning the mental stability of the climber in the above photo. That’s Alex Honnold, by the way, the World’s premier free-solo climber. We men don’t have to be exactly like Mr. Honnold but all of us can still strive to be the best we can be, especially as we age.
Most of us are dealt a pretty good hand of hormone cards to start with but it’s very easy to misplay that hand as we leave our twenties in the rear-view mirror due to the accumulated effects of stress. Never mind pandemics, I’m talking about the stress of the daily grind: long commutes, too much to do at work, running children around to various activities, not enough time to eat properly, be a good partner, get enough sleep, get enough exercise. Pretty soon you can find yourself feeling like you’re about 20 years older than it says on your Driver’s License.
But there’s hope.
If you find yourself in the situation I just described, the prudent thing to do is consult an Integrative Medicine (IM) practitioner. You could “go it alone” using information on the web to make lifestyle changes but my opinion is that you need to find out if there are significant hormone/metabolic issues that need attention. If there are such issues and you don’t address them, then you probably won’t have the focus, determination and energy to make the needed changes in your lifestyle. You also might miss something if you “go solo”. For example, sleep apnea is common and can play havoc with how you feel. It needs expert medical attention.
Your IM practitioner will want to assess your biochemical status through a variety of tests assessing a few major issues. This list is by no means definitive but hits most of the high notes:
- thyroid hormone status
- how much cortisol you’re making and how you’re managing that cortisol
- testosterone, estrogen, DHEA levels and patterns of their downstream metabolites
- markers of inflammation such as uric acid, hsCRP, homocysteine, GGT
- how much insulin you’re making and how well it’s controlling your blood sugar
- levels of basic vitamins and nutrients such as Vitamin D, Vitamin A, B12, essential fatty acids, zinc, magnesium, Coenzyme Q10
The same concepts will apply for women noting that other hormones such as progesterone and allopregnanolone are more relevant for females.
In particular, along with simply feeling older than we are, we men can develop prostate issues. I’ll run over the rationale for the testing strategy outlined above but also spend some time focusing specifically on the prostate.
Two of the hormones listed above deserve top billing: thyroid and cortisol. If you run too low on either of these hormones it can eventually become life-threatening (Not the case with the sex hormones!).
Your thyroid gland produces two primary thyroid hormones: T4 and T3. T3 is the more potent form and it does the heavy lifting inside cells. The thyroid hormones play a central role in regulating cellular ATP (energy) production and utilization, and they interact with other hormones such as testosterone, cortisol and insulin. Thyroid hormones can be thrown off by too much exposure to chemicals in the environment, by dysregulation of the immune system by viruses, food sensitivities, medications, overzealous use of certain supplements and overdoing certain foods such as kale. Regardless of cause, a thyroid hormone problem can have a domino effect on other hormones. Conversely, fixing a thyroid hormone problem can almost miraculously cause everything else to line back up.
Cortisol has a central role to regulate fuel (glucose and fat), fight inflammation and act as a counter-regulatory hormone, balancing the effects of thyroid, testosterone and insulin hormones, to name a few. Just imagine if you only had an accelerator to control the speed of your car. You also need a brake. Cortisol provides that brake. If your cortisol is too high due to chronic stress, this will suppress your testosterone. If you are facing chronic stress/high cortisol, your body makes the call that you have no business trying to reproduce so it will throttle back on testosterone. Conversely, if your cortisol production is too low, testosterone and other hormone levels can be dragged down with it.
Testosterone isn’t just about reproduction though. It is a key hormone, affecting body composition, cardiac health, bone health, energy, mood, cognition, drive, and last but not least: sense of humor. Testosterone normally declines gradually with age but even in older age, many men have a testosterone level that is low compared to their peers, with serious consequences.
Testosterone and estradiol have a unique relationship in that testosterone can be converted into estradiol by an enzyme called aromatase. Aromatase is present in various tissues including intrabdominal fat (more on this in a minute). Testosterone and estradiol are like yang and yin: complementary but intertwined.
The brain regulates testosterone production by monitoring both testosterone and estradiol. If the brain sees too much estradiol, and since it “knows” that estradiol comes from testosterone in males, it can decrease the signals telling the testicles to make testosterone.
Concerningly, testosterone levels in males have been declining steadily over the last twenty years (Lokeshwar 2021: study of males aged 15 to 40) and one of the causes is thought to be an increase in obesity. Too much abdominal fat: too much estradiol: too much estradiol, not enough testosterone. Fat loss may be one way to increase testosterone by reducing estradiol production.
But there’s another more insidious process at play, which is the effect of ubiquitous chemicals in the environment/food/water that affect the brain in the same way as estradiol. These chemicals are called xenoestrogens. Xenoestrogens might also impair the proper develop of testosterone-sensitive tissues in the fetus.
If you have too much homegrown estradiol, low doses of prescription medications to inhibit the action of aromatase can be prescribed. These meds are used to treat breast cancer, which by the way, can occur in females AND males. There are dietary supplements which can help your liver to clear estrogens from your system more effectively and there are other strategies to promote clearance or “detox” of stored xenoestrogens. Avoidance of exposure to xenoestrogens with water filtration, better food choices and label-reading also help to lower xenoestrogen burden. Once you know the names of the bad xenoestrogen actors, such as PCBs, BPA, and phthalates, it’s possible to reduce your burden substantially. There are many books written on this topic. Here’s a recent one:
Just to complicate matters, there’s another hormone called DHEA, produced by the adrenal glands. Its levels also go down with age. DHEA can spawn both testosterone and estradiol, but judicious supplementation with DHEA can often be helpful. Again, a urine steroid test can shed light on the overall pattern of these interlocking hormones. I think a good urine steroid hormone panel is the ONLY way to go, to sort out the puzzle.
As I’ve discussed before in other posts, unrecognized inflammation is often at the root of many health issues including accelerated aging. Inflammation in fat cells drives them to further accumulate fat, contributing to more estradiol formation by aromatase. Consumption of processed foods loaded with high fructose corn syrup (which goes by a wide variety of aliases) can drive up uric acid which contributes directly to inflammation, insulin resistance and more weight gain. When insulin resistance is present this means that your body must make excess insulin to keep blood sugar levels under control. This can eventually lead to diabetes. Inflammation, insulin resistance, low testosterone and elevated estrogens go hand in hand.
Repeating myself here, I think that optimizing or improving your health needs to be addressed with the guidance of a trained Integrative Medicine practitioner. I’ll note that you could sidestep all of the foregoing and simply start a fitness/dietary regimen on your own. Lord knows, there is enough information available on the web, courtesy of bodybuilders and biohackers. Many of them know more than I do. Weight training and fat loss can have an amazing effect on male (and female) health. But as I said, depending on where you’re starting from, it’s a good idea for most men to have a thorough assessment and work with an expert.
Prostate Health
I could fill an entire post talking about the prostate. Certainly prostate cancer lurks in the back of the minds of most men as they age. Supplementation with testosterone (TRT) has tended to get a bad rap in the past and was thought to promote prostate cancer but more recent literature indicates that this is not the case (Bhasin 2018, Lenfant 2020), although there are various relative contraindications to TRT such as severe sleep apnea and heart disease. Restoring a low level of testosterone back to normal may actually help to prevent prostate cancer.
Setting aside concerns about cancer, the other prostate issue confronting men is non-cancerous enlargement of the prostate, or Benign Prostatic Hypertrophy (BPH), which presents with symptoms including difficulty urinating, slow stream, frequent urination, sleep disruption. Two factors that promote BPH are the same ones that can lead to low testosterone: inflammation and excessive estradiol production within the prostate. Note that the same measures that would be taken to influence systemic inflammation and high estrogens apply for BPH.
You may have heard of a steroid hormone called dihydrotestosterone or DHT. Within target cells including prostate cells, testosterone can convert into DHT which is roughly five times more powerful than testosterone. DHT is important for the maturation of tissues sensitive to testosterone in the urogenital tract as it “amplifies” the testosterone signal. However, in later life DHT may play a role in prostate enlargement and may also be responsible for the hair we start to grow places like our shoulders and earlobes. Testosterone can also convert into DHT in hair follicles, encouraging sometimes-exuberant hair growth.
There is a long list of natural remedies that are useful to address low testosterone, high estrogens, inflammation and BPH. These include but aren’t limited to: pumpkin seeds, zinc, quercetin, boron, curcumin and saw palmetto.
I know I sound like a broken record, but your Integrative Health practitioner can work with you to help you navigate a path to a better alignment between how you feel and what that Driver’s License says. And if you wind up emulating Alex Honnold, be my guest!
Stay tuned for the next post later this month when I’ll discuss a fascinating non-invasive, non-drug treatment that can reduce the symptoms of BPH!
Author: George Gillson, MD, PHD, CCFP
EvolveWell Medical Director
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