Testosterone is a powerful hormone for both men and women. Without it people feel less energy, lower vitality, reduced libido, and brain fog. In addition testosterone deficiency puts you at risk for losing muscle mass, gaining weight and suffering from reduced bone quality and quantity. Men in particular seem to be at higher risk of death when levels are not maintained. However, despite all of these associations testosterone is not generally tested as a part of normal prevention visits and natural ways to improve testosterone are rarely a part of general wellness plan. Worse yet, replacement when indicated has become something many patients are afraid to discuss with their health care team which drives care to online dispensaries and programs with a wide range of care and sometimes concerning quality. At OHH we look at testosterone in men and women as a part of optimization and not through a narrow lens. The big picture MUST be addressed or the benefits of having optimal levels goes down and risk goes up. We never want to optimize at the expense of safety. The time and effort spent on your health should make you feel better and improve longevity, never the other way around!

Testosterone deficiency is an issue in 3 specific groups for different reasons. Men see a natural decline in testosterone with aging in a process called andropause. It is a more gradual decline in hormone levels than what women see in menopause but at a varying thresholds the loss of androgens can cause men to suffer from all of the symptoms mentioned above but also the most common reason for testosterone searches, loss of libido and erectile dysfunction. Testosterone deficiency is not only seen in aging men though. We see extremely low numbers in men starting in their 20s for multiple reasons. This study demonstrates that total testosterone levels in men have been decreasing over the last several decades. This means that the natural decline is starting from a lower point and as such symptoms will be noticed at an earlier age. The change is occurring for many reasons. I believe the most significant being chronic stress but obesity, our toxic environment, lifestyle, poor nutrition and chronic exercise habits likely play a part.

Women suffer in two distinct groups. A very common pattern we see in younger premenopausal women is high stress leading to chronic adrenal dysfunction. While testosterone in men is made exclusively in the testes women have two sets of organs that share this responsibility. Both the adrenal glands and ovaries make testosterone in variable amounts as woman age. When chronic stress results in overproduction of cortisol or even worse complete exhaustion of the adrenal glands testosterone levels decline. This leaves these young women with less energy, less muscle mass, slower metabolism, reduced libido, early decline in bone health and more. Post menopausal women lose testosterone production in the ovaries along with rapid drops in estrogen and progesterone. The adrenal glands can maintain some testosterone production but not enough to prevent loss of lean muscle mass and bone quality and quantity in addition to the signs of low testosterone already discussed.

To make this topic even more confusing there is controversy in both definition and testing around testosterone levels. While multiple societies have accepted definitions of low testosterone in men there is no accepted objective metric in women and no discussion of symptoms of low testosterone in either sex. As a result many patients are told that there levels are fine without a discussion of symptoms and for women the reference range or acceptable range for free testosterone includes 0, so even with no testosterone her labs are still “normal” but far from optimal.

There are numerous causes contributing to this epidemic of low testosterone in both men and women. Chronic stress, and poor sleep are the largest contributors we see at OHH but immune dysfunction, visceral fat accumulation, toxins, poor nutrition and chronic infections are also to blame. Unwinding the web of potential causes is part of the optimization process and involves extensive history taking and sometimes testing to find the source and change the course.

Probably the second greatest contributing factor of testosterone deficiency across the western world is obesity. Visceral (belly) fat associated with most cases of obesity has a unique ability to reduce testosterone levels. Visceral fat acts like a tumor and secretes hormones and signals in an attempt to get what it wants, to get fatter. These patients generally have elevated levels of a hormone called insulin which is secreted in an attempt to control blood sugar. Long before a patient exhibits signs of elevated blood glucose and diabetes insulin levels rise and stay elevated. This results in lower testosterone and dysfunctional testosterone receptors. Visceral fat also secretes IL-6 and other inflammatory cytokines which cause inflammation throughout the body. This also tells the brain to reduce testosterone production. Lastly, visceral fat contains the enzyme aromatase which converts testosterone to estrogen, so even if you manage to produce testosterone it will quickly be converted to estrogen. This last mechanism is an issue for both men and women as neither sex does well with elevated levels of estrogen!

Another culprit of testosterone depletion that is frequently misunderstood is exercise. While some activities like resistance training can raise testosterone others can reduce it. Chronic exposure to endurance training “cardio” has been shown to reduce testosterone over time. This can clearly be seen when comparing athletes such as professional cyclists and marathon runners to body builders and power athletes. The calories in calories out dogma has resulted in the common idea that more time on the treadmill is the answer to weight loss and health. The opposite in fact may be true. There is a place for endurance training but recognizing the limits of that approach and how they relate to your goals is important. If you are looking to maintain or lose weight, increase your testosterone, maintain muscle mass and protect your bone health? Lift something heavy. If you aren’t comfortable doing so on your own hire someone to help you learn how.

So, to put it all together our approach at OHH is to take a broad look at your pillars of health. We explore your sleep, activities, nutrition and stress management before we ever make a recommendation. Supplements such as Tongkat Ali, Tribulus and Zinc are commonly used to improve testosterone levels. We have a list of numerous options depending on unique scenarios. These combined with lifestyle changes and resistance training can make dramatic improvements!

Lastly, if lifestyle, exercise, nutrition and supplementation can’t get you where you need to be or you are a post menopausal woman, replacement may be your only option. There should be NO shame in this. Our society has vilified it to some extent for both sexes but choosing to maintain your vitality and health with natural hormone levels is a powerful way to improve your healthspan. There are several options for both men and women and a discussion of the risks and benefits that are unique to every patient MUST be had in order to fully understand how replacement can help or put you at risk. When we replace hormones at OHH we thoroughly test not only the hormones in question but labs that can help stratify risk and assist in decision making. Our program includes follow up testing to make sure that levels are physiologic and other markers are not getting worse. Regardless of how you are getting there, having optimal hormones should be a wonderful experience that should provide you with energy, focus, vitality and joy in your life.

Dr. Doug

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