Episode 14 – Andropause (a.k.a. “manopause”, male menopause)

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In this episode, we discuss the diagnosis and treatment of andropause (a.k.a. “manopause”) from a holistic perspective.

Topics include:

  • Basic physiology and pathology of andropause
  • Can vasectomies contribute to early onset of andropause?
  • The best non-pharmaceutical approaches to preventing andropause?
  • Blood and saliva markers for andropause
  • What role libido/erections play in determining health?
  • Should andropause be accepted as a normal physiological process in aging males?
  • Is a “beer belly” and are “man boobs” signs of andropause?
Play

Full Text Transcript:

Danny Roddy: Hello everyone and welcome to the Healthy Skeptic podcast. My name is Danny Roddy and with me is Chris Kresser, health detective and creator of thehealthyskeptic.org, a blog challenging mainstream myths about nutrition and health. Chris, I missed you  last week, how are you doin buddy?

Chris Kresser: Yeah we missed you Danny, I don’t know if you had a chance to listen to it but it was a lot of fun.

DANNY RODDY: I did Emily is truly amazing I really enjoyed the episode.

CHRIS KRESSER: Yeah she is a popular guest too, we got a lot of comments saying best podcast ever so, we’ll have to have her back for sure.

DANNY RODDY: Awesome how’s the lady? how’s the forthcoming baby?

CHRIS KRESSER: Both good as far as I can tell, there’s a fully formed baby in there, so it could be any day, could be today. Could be two weeks from now we really don’t know but we’re sort of making predictions just cause it’s fun. And my prediction is two or three days before the due date which would be like the 14th or the 15th, but it’s just a wild guess I have no idea.

DANNY RODDY: It could be during this podcast.

CHRIS KRESSER: Who knows? Stranger things have happened; you’ll forgive me if I have to stop in the middle of it. How about you, what’s happening?

DANNY RODDY: Nothing new as I told you I just moved, but really keeping busy with summer school, and that’s pretty much it.

CHRIS KRESSER: That’s biology now?

DANNY RODDY: Yeah biology, taking some general ed classes like english and communications. I’m really lucky I get to take these accelerated classes which are in my opinion way easier, so I’m getting it all done super fast since I didn’t do it when I was doin the whole band thing.

CHRIS KRESSER: Nice, glad you got out of that stupid nutrition program.

DANNY RODDY: Yeah that was, well I sat in the back and didn’t raise my hand anymore and that kinda solved the issue.

CHRIS KRESSER: Right. Alright so today’s topic is everybody’s favorite topic man-o-pause.

DANNY RODDY: Man-o-pause, best topic ever.

CHRIS KRESSER: Otherwise known as male menopause or andropause, if we wanna get technical.

When does Andropause (a.k.a. “manopause”, male menopause) strike?

DANNY RODDY: Chris, beginning question does this hit men at any age? A certain age? Or do you see men all across the board with this?

CHRIS KRESSER: It certainly can happen earlier rather than later, it’s not typical to see it in the early twenties  but it can, and we’re gonna cover why that is. Man-o-pause, just to back up a little bit in case some of our listeners don’t know what man-opause or andropause is, it’s basically a slow, usually a slow but steady reduction of the production of testosterone and dihydrotestosterone, which are the main androgens, or male hormones. And then the consequences of that reduction, which is usually associated with a decrease in leydig cells in the testicles. So man-opause, as you hinted is a little bit different than menopause in this way… In the case of menopause there’s usually a pretty dramatic and abrupt shift that happens in female hormone levels. Any woman that’s gone through menopause and experienced it in this way will tell you how abrupt and dramatic it could be. But the changes that happen in make reproductive hormones are often but not always more subtle. And they tend to occur more gradually through life. But as with menopause these changes can have pretty serious implications. For example, I know we talked about this before but the ten most common causes of death in males are heart disease, cancer, accidents (or unintentional injury), stroke, lower respiratory diseases, diabetes, fluid pneumonia, suicide, kidney disease, and Alzheimer’s. And when you look at those ten causes it’s pretty clear that andropause can play a role in nearly all of them if not all of them. So it’s definitely a serious problem and I haven’t seen any solid data on this but just anecdotally, having been in practice for a while and even back into my student days, it seems to me that I’m seeing more men with these complaints. What do you think? I know because of the work with hair loss and since that’s a major symptom of it you must see some of this too.

DANNY RODDY: Totally,  I think it really becomes apparent when people at work I’m like known as the health guy, and as you know I think people are really willing to share information with you that they wouldn’t otherwise. So people always say I have digestive issues or I have  no libido, and I don’t know if I’m just privied to that information but it’s definitely something that happens commonly.

CHRIS KRESSER: And I’m seeing it more in younger guys at this point too. In their thirties and forties, and even some in their twenties. We’ll talk a little bit more about how that could be possible and it will make a lot of sense once we get into the patterns. But before we do that I wanna talk a little but about basic male hormone physiology, because it’s important to understand how that works in order to really get the mechanisms that occur when things go wrong.

The basic physiology and pathology of Andropause

So, male hormone production and any hormone production, male or female, involves the hypothalamus in the brain and the pituitary, and in the case of males involves the testicles and in females it involves the ovaries, and too a lesser degree in both the adrenals. So the whole process starts with gonadotropin releasing hormone or GnRH, which is produced in the hypothalamus. And then at the level of the pituitary GnRH stimulates the release of FSH, follicle stimulating hormone and LH which is luteinizing hormone. And then it kinda breaks off in two different directions. LH acts on the leydig cells in the testicles which produce testosterone. And then that testosterone is converted into dihydrotestosterone which is a downstream metabolite of testosterone that’s about ten times more metabolically active. The enzyme 5-alpha-reductase is involved in that conversion and we’ll come back to that late because one of the pathologies of man-opause involves that enzyme. In the other pathway FSH acts on the sertoli cells in the testicles which produce sperm. So keep in mind that the production of testosterone depends on precursor hormones like 17-hydroxyprogesterone, pregnenolone and DHEA, all of which can be depleted in the stress response and diverted into cortisol production. So for example if you’ve got too much stress, that can deplete these testosterone precursor hormones and lead to lower levels of testosterone and we’ll talk more about that later too.

It’s also important to understand how hormone regulation works in general in the body. It’s a negative feedback system so  one analogy I like to use is, you can think of the pituitary gland as a control tower and it basically sits up in the brain monitoring hormone levels in the blood. And if a hormone level is low, for example if testosterone is low, then the pituitary will pick up on that and it will increase the production of the stimulating hormone, in this case LH that acts on the leydig cells to produce more testosterone. On the other hand if testosterone were high then you would see a decrease in LH, so that the testicles would produce less. And that’s basically how it works with any hormone in the body and it’s a really exquisitely controlled and regulated system and there are still parts of it that we don’t really understand that well. So it’s important to keep that in mind because when we talk about things like testosterone replacement therapy or hormone replacement therapy, one of the issues with it is that it disrupts that carefully orchestrated natural regulation and the negative feedback system and we’ll talk more about that as well.

DANNY RODDY: Chris are you saying I can’t balance the delicate symphony that is the hormonal system with testosterone cream?

CHRIS KRESSER: That is what I’m saying, we’re gonna talk a lot about this but I do also wanna say that there are some cases where testosterone replacement is helpful and so I’m not saying there’s no place for it and it’s never beneficial, I’m just saying it certainly should not be the first thing that somebody tries and I’m also suggesting that it really depends on the mechanism. You need to figure out why testosterone levels are low and then address the particular mechanism, otherwise it’s just a band-aid solution and of course as you’re implying and we’ve already talked about you can end up causing more problems than you’re trying to fix.

So let’s about five main patterns of man-opause, so these are like five, at least as far as I’ve seen in my practice and in the literature these are five typical presentations of man-opause. So number one would be over-conversion of testosterone into estrogen via aromatization. As you know, males should be androgen dominant, or testosterone dominant, and if a lot of testosterone gets converted into estrogen then all kinds of problems ensue. One interesting thing is that in males, testosterone is actually protective against heart disease, whereas in females estrogen is protective against heart disease. So in males when they become estrogen dominant, they become more susceptible to heart disease. And I think that’s actually one thing that’s not really talked about very often in terms of these increasing rates of heart disease is this pattern of man-opause and how that is contributing to the increased risk of heart disease. And women it’s the opposite, when women convert too much estrogen into testosterone which is common with PCOS and caused by insulin resistance, then their risk for heart disease goes up.

DANNY RODDY: Is  there a known mechanism for how testosterone protects the heart?

CHRIS KRESSER: There probably is but I can’t tell you what it is. My sense of it is just that, again there’s such a delicate balance of hormones in the system and hormones regulate so many different processes and if that goes out of whack then pretty much everything can go out of whack along with it.

So number two would be increased production of sex hormone binding globulin which then leads to low levels of free testosterone. So in order to get this we need to explain a little more about how hormone regulation works in the body. Generally when hormones are produced by the gland that produces them, they are attached to a carrier protein. That’s because hormones are not water soluble or soluble in the blood they’re fat soluble. So in order to be transported through the blood they need to be attached to a protein carrier. In the case of thyroid that carrier is thyroid binding globulin, but in the case of sex hormones it’s sex hormone binding globulin. However in order for the hormone to become biologically active and act on the tissue or the cell it needs to be cleaved from that carrier protein. Once it becomes cleaved from that carrier protein it’s then referred to as free hormone. Once testosterone is cleaved from sex hormone binding globulin it becomes free testosterone. So this is why you hear people emphasize the importance of testing free hormone levels rather than just the protein bound hormones. Because protein bound hormones, it’s still important to test that because that’s what tells you how the gland is functioning. Protein bound hormone levels tell you how much of a hormone that the gland is actually producing. But it’s also important to test the free levels because that tells you how much of the hormone is actually biologically active. So in this pattern that we’re talking about here you get an increased production of the carrier protein sex hormone binding globulin which if you follow, the more carrier proteins you have the less free testosterone will be left over to act on the tissue.

DANNY RODDY: Bad news.

CHRIS KRESSER: Bad news, no fun. So pattern number three is leydig cell failure, so the leydig cells that produce the testosterone have failed or are not functioning properly, and then you’ll get an elevated level of LH because of that negative feedback system we described earlier where leydig cells are not producing testosterone, the levels of testosterone are low as a result, and then the pituitary picks up on that and it cranks up the level of luteinizing hormone in order to stimulate more testosterone production. But because the leydig cells aren’t working well they don’t get that memo, or they become insensitive to it in the same way that cells can become insulin resistant. So the pituitary is shouting at the testicles and the leydig cells telling it to produce more, but it can’t hear that message. So, that’s usually secondary to inflammation, which we’re gonna talk a lot more about.

Pattern number four would be up-regulation of 5-alphareductase which is the enzyme that coverts testosterone into dihydrotestosterone. And that can lead to an increase production of dihydrotestosterone which can cause problems like benign prostate hyperplasia, BPH, and as of course you will know Danny, it can cause hair loss.

There’s another pattern which would be a down-regulation of 5-alphareductase which is less common where you see elevated levels of testosterone or elevated or normal testosterone but low levels of DHT. And since DHT is so much more potent than testosterone in its metabolic effects, low levels of DHT can lead to some of the symptoms of hypogonadism or andropause.

DANNY RODDY: Chris, this is a wild guess but is it true that the more DHT one has the more beard and auxiliary hair they usually have? To my understanding DHT is responsible for a lot of male characteristics like beard growth.

CHRIS KRESSER: Yeah I think so. I mean we probably all have that guy who we grew up with who got a beard when he was in fifth grade. I won’t name any names but if anyone here we went to school with is listening to this show they’ll know who I’m talking about. Poor guy got a pretty hard time but seriously he could go into a liquor store and buy beers when he was in sixth grade. But yeah I think he had some extra DHT floating around in his system.

So pattern number five is chronic stress, which depresses pituitary function. Depressing pituitary function can leads to decreased levels of LH and FSH which of course are the stimulating hormones that tell the leydig cells and the sertoli cells to produce testosterone and sperm. So this is one of the mechanisms by which stress can not only cause andropause but can cause infertility because if you a decrease in sperm production that’s obviously not gonna increase your chances of conception.

So now let’s talk a little bit, those are the five main patterns but the obvious question is what causes those patterns to happen, what are the main mechanisms that lead to those patterns and this of course is gonna inform how we deal with them. So the first one is insulin resistance and keep in mind as we talk about each of these mechanisms, in most cases each mechanism contributes to most, if not all of the five patterns we just talked about. And it’s sort of a cycle, so the mechanism, like insulin resistance, will cause one of the patterns and then one of those patterns contributes to some of the other patterns and then you get into that whole downward spiral thing. So insulin resistance and low testosterone have been shown in several different studies to occur together in diabetic men, they were associated, because insulin up-regulates the production of aromatase. We talked about this in that first pattern the over-conversion of testosterone into estrogen via aromatization. So aromatase is the enzyme that converts testosterone into estrogen. So what happens is when you have elevated insulin, or insulin resistance, you get an increase in that enzyme aromatase and then you get an increased conversion of testosterone into estrogen. Now elevated estrogen levels increase the production of sex hormone binding globulin. And as we just discussed that will decrease the level of free testosterone. And a third way that insulin resistance mucks everything up is that it of course contributes to weight gain. And we know now that adipocytes, or fat cells from body fat, release interleukin-6 which is an inflammatory cytokine that contributes to man-opause in several different ways and we’re gonna talk about that next when we talk about inflammation. And then finally insulin resistance also triggers the release of GnRH and so hypogonadism could be the result of insulin resistance that’s occurring at the level of the hypothalamus.

Okay so now let’s move on to the next mechanism which is inflammation. Interesting thing about this, as I said, is all of these things start to interrelate and it becomes a really nasty viscous cycle so if you’ve read my series on di-obesity you know that insulin resistance can contribute to inflammation and inflammation can contribute to insulin resistance so keep that in mind as we talk about this stuff. So inflammation can reduce testosterone production several different ways. Inflammatory cytokines can alter the growth and differentiation of leydig cells. And it can also inhibit the production of testosterone by leydig cells at the transcriptional level of the steroidogenic enzymes. I know that was a mouthful… So in other words inflammation suppresses the transcription  of enzymes which are needed to produce testosterone. And then inflammation can cause testicular resistance to LH, which is what we were just talking about before when I was saying how the pituitary is shouting at the testicles to produce more sperm or testosterone but the testicles can’t hear because they’re resistant to LH. It’s the same phenomenon as insulin resistance or thyroid hormone resistance.

The third main mechanism is stress. And again, stress can lead to elevated cortisol levels we’ve talked about this ad naseum, lots of different times. Cortisol levels when they’re elevated disrupt blood sugar regulation, and that can lead to insulin resistance. We know that calorie restriction, like long term dieting, and poor sleep have both been shown to alter the secretion of GnRH and LH, which in turn would decrease testosterone levels. I saw a study where daytime testosterone levels were decreased by 10-15% in young men who were otherwise healthy who underwent a week, just a week, of sleep restriction to five hours per night. So that’s a condition that 15% of the U.S. working population experiences, is either working the night shift or working a late shift so they can only get five or six hours of sleep per night and in just one week of that testosterone levels were decreased by 10-15%. Now compare that to a decrease in testosterone levels of 1-2% per year which is associated with normal aging, that’s a pretty big difference. And these men, the symptoms we’re talking about here are things like low energy, reduced libido, poor concentration, increased sleepiness, and then more significant stuff like increased risk of heart disease, increased risks for dementia and alzheimer’s which we’ll talk about in a second, and pretty much all of the major causes of death that we talked about before.

So the last thing I wanna talk about before we get into prevention and treatment and some of the questions, is testosterone and the brain, and the relationship between the two. So in addition to the stuff that we just covered, low testosterone can also alter mood and memory and the ability to concentrate. And this is why loss of testosterone is associated with dementia and Alzheimer’s. On the other hand, when you have decreased blood flow to the brain and activation of the microglia which are the immune cells in the brain, and microglia activation of the brain equals inflammation of the brain. That can in turn suppress the function of the hypothalamus and the pituitary and lead to low testosterone levels. We know that long term elevations of LH which occur in testicular resistance, which is again secondary to inflammation, can promote degeneration of the hippocampus and the hippocampus is the part of the brain affected, and degenerated in alzheimer’s and dementia. The hippocampus also controls cortisol rhythm and so this is another viscous cycle that you get into where you get an elevation of LH that degenerate the hippocampus, the hippocampus controls cortisol rhythm so then you get a disturbed cortisol rhythm which causes more stress and more inflammation which leads to further degeneration of the hippocampus and we’re off to the races.

One interesting too, is that a lot of recent research suggests that erectile disfunction in men is generally not an endocrine problem, it’s not a problem with hormone regulation as much as it’s a vascular and neurologic problem. So what’s happening is there’s not enough blood flow to the peripheries and that’s what’s causing the erectile disfunction rather than a hormone imbalance. And a couple recent studies that I saw suggested that erectile disfunction may actually be the first sign of systemic vascular disease, or cardiovascular problems in other words erectile disfunction might be an early indicator or early warning of future cardiovascular complications because of the relationship with blood flow there.

Okay so let’s just talk a little bit in a general sense about prevention and treatment because that’s all we can really do without, I always harp on this but it’s really different for every individual because each individual is gonna have a different presentation with different mechanisms, different patterns, and it’s really important to identify what those patterns are to create the most effective treatment. And that’s why I’m never comfortable just saying go out and take tribulus, or gymnema or this because it’s kind of a shotgun approach that might work if you happen to be one of the people where your LH is decreased and that’s the mechanism and tribulus increases it you get lucky but if you’re not it’s not gonna help and at worse it can cause harm.

The best non-pharmaceutical approaches to preventing Andropause?

Let’s talk a little bit, I know we’ve already covered this but let’s talk again about why testosterone replacement isn’t the best place to start. We talked about the whole negative feedback system earlier in the podcast, and what happens then if you take a testosterone cream, you rub it on your skin, there’s a few things there. Number one, I explained earlier that the body has a really complicated way of determining hormone balance. And beyond that, it decides in a way that we don’t fully understand yet, when to cleave the free hormone from its protein carrier and make it active to the tissues. So the body orchestrates that process in a way that we don’t understand and what happens when you take testosterone cream is that’s free testosterone in that cream. So it goes right into your blood, into your tissues and into your bloodstream as free testosterone. So the body has no ability to regulate how much free testosterone is available to the tissues when you take the cream because it just enters the tissues in the free form. The body has no choice about cleaving it from a protein carrier.

So that’s problem number one. Problem number two, which is the more general problem is that as the levels of testosterone rise in the tissue, because of the negative feedback system the pituitary will produce less LH and FSH to try to compensate. But because it’s not the glands that are producing that excess hormone it’s coming from outside of the body, the decrease in LH and FSH doesn’t really have any affect. And you often see a further decrease in LH and FSH as the body scrambles to compensate for the increased testosterone levels. Now that means of course that you’ll have decreased internal production of testosterone, and then what happens in any case where there’s excess hormone floating around is that the cellular receptor sites for that hormone will become down-regulated. It’s a smart way that the body has of protecting itself from too much hormone exposure. So not only do the receptor sites become less sensitive to that hormone, like testosterone in this case, you’ll actually see a decrease in the overall number of receptor sites on the cell. And then what happens at that point is that you’ll need to take more testosterone cream to get the same effect, because you have fewer receptors and the receptors you do have are less sensitive. And then the LH and FSH continue to decrease which means you’re producing internally less and less testosterone and so over time a guy who’s on the cream might need to take more and more to have the same effect, keep increasing the dose and then at some point they just might give up, it’s not working anymore, and then they stop the cream. What do you suppose happens then?

DANNY RODDY: A world of hurt.

CHRIS KRESSER: Exactly. Because when they stop the cream they have fewer receptors, the receptors they do have are totally insensitive, and their LH and FSH are completely depressed from all of the time on the cream so they’re not producing any of their own hormone. And when I see this in my practice I tell people honestly this is gonna suck. You’re gonna be in a world of hurt for a few months as we deal with the situation and there’s no way around it unfortunately. I actually don’t take people off cold turkey because of this, I usually try to titrate them off over time. But inevitably there’s a period where we remove the external support and the internal production is not caught up yet. But the good news is that receptor sites can come back, so once the body figures out that there isn’t any excess in the tissues anymore then the LH and FSH will start to come back and the internal production of the hormone will start to come back and then the number of receptor sites will increase and the sensitivity of the receptor sites that exist will increase. So it is reversible in many cases.

DANNY RODDY: Would you put a number on that for how long that takes for a gentlemen?

CHRIS KRESSER: I definitely would not.

DANNY RODDY: I know it’s different for everybody but a couple of months? or…

CHRIS KRESSER: Months yeah. Months, it’s a function of how long they’ve been on the cream of course, and then how down-regulated their receptors and LH and FSH are. But in general I would say that the transition period is at least two months and maybe somewhere between two to four months. It’s not like there’s nothing changing during that time there’s a gradual shift happening but it can be difficult for those couple of months for sure.

So what else can be done? If not TRT, or testosterone replacement therapy, what can we do? Of course the answer depends on first identifying the underlying mechanism that’s always more than half the battle. Which pattern is it? Is it aromatization? Over conversion of testosterone into estrogen? Is it inflammation, is it stress, all of the above? And then of course once you figure out what that pattern is you’ve gotta address it at that root level. If it’s insulin resistance you’ve got address glucose tolerance and blood sugar regulation, insulin sensitivity. If it’s inflammation you need to look first of course at diet, are there food toxins in the diet that are contributing to inflammation, is there over-training happening, is there some other cause of inflammation like a chronic infection that hasn’t been identified. You’ve gotta look at stress and sleep, which I think in seriously probably 90% or maybe 95% of cases of andropause stress and sleep deprivation is running the show. It’s the thing that people have the most trouble focusing on, especially men it seems. And it’s one of the hardest things to focus on as we’ve talked about a lot. It’s a lot easier to take tribulus or some other supplement than it is to radically change one’s lifestyle. If adrenal stress is the primary driver, which it often is then stress management programs like mindfulness based stress reduction or the rest assured program which you can get at soundersleep.com, we’ve talked about these before. Herbal adaptogens can be helpful, things like ginseng, rhodiola, ashwagandha, eleutherococcus, these are botanicals that can increase cortisol when it’s low and decrease it when it’s high, which is the definition of an adaptogen it’s a pretty neat thing that plant medicine can do that drugs can’t do generally. Then there’s phosphatidylserine which protects the integrity of the hippocampus, helps regulate the cortisol rhythm, helps with cognitive function overall. Those are some basic ideas. And of course if there’s insulin sensitivity you’ve gotta take of the diet, but if you’ve already taken care of the diet and you still are dealing with glucose intolerance or insulin sensitivity things like gymnema which is an herb that’s been used in Ayurvedic tradition in India for hundreds of thousands of years to decrease sugar cravings and improve insulin sensitivity and glucose tolerance. Magnesium is really good for that, green tea extract and alpha lipoic acid can be helpful. Then there’s chrysin which has come up before, chrysin is one of the few compounds that we know of that inhibits aromatization, which is that over-conversion of testosterone to estrogen so if that pattern is present in addition to of course doing everything you can to decrease insulin resistance, chrysin might be helpful. And then maca and tribulus increase LH production and of course these are the two supplements that you see on the internet recommended all the time, like if you have low testosterone take tribulus and maca. It’s not that simple but consider this possibility, let’s say the mechanism is testicular resistance and you actually have high LH. Taking maca and tribulus is not gonna help that problem and arguably it could make it worse by increasing the testicular resistance. But if you do have decreased LH production, and this is what we’d suspect for a guy who’s been on testosterone replacement therapy and is coming off of it, we would expect their LH and FSH production to be low, and I’ve found in these circumstances that maca and tribulus can be helpful in bringing LH production back up to a normal level.

DANNY RODDY: I was gonna throw in working with somebody like yourself might be the key to getting these herbs to actually function correctly.

CHRIS KRESSER: Yeah or finding anybody who has this kind of perspective, a functional perspective who’s looking at the underlying mechanism, doing the appropriate testing to determine what that mechanism is and then creating a treatment plan that’s based on that data. Rather than just prescribing an herb for a symptom.

DANNY RODDY: Because herbs can be equated to medication almost.

CHRIS KRESSER: Yeah absolutely, they’re very potent. And a lot of people don’t understand that. There’s a sad story, I haven’t talked to this guy in a while. He is a patient and I might be screwing up the details but he took an herbal formula, it was something he got off the internet. It was for andropause, he had borderline low levels of testosterone and it had an herb in it. I can’t remember the name of the herb right now but it’s one of the herbs that you see recommended a lot for increasing testosterone not a lot it was kind of a lesser known one actually. And he had complete, irreversible at least up until now, impotence after taking this product formula. It changed something really significantly and I only spoke to him once I think we did an initial consult and he told me about it and then I didn’t talk to him I’m not sure what he ended up doing.

DANNY RODDY: Did you guys ever end up doing blood work or anything?

CHRIS KRESSER: No he didn’t follow through, I’m not sure what he ended up deciding to do but that’s rare. It’s not like you hear about that often but it does underscore the importance of finding some help with this sort of thing, because one of the thing things about herbs is that they’re not regulated by the FDA and in some ways I think that’s a good thing because I certainly don’t want the FDA deciding what herbs I can prescribe or not but the downside of that is that there’s a lot of variation in quality out there. Being an herbalist I’ve studied this in depth and I can tell you first hand that there’s a huge, huge difference in the quality of herbal products out there. The typical Chinese herb product has been harvested ten years ago, it then sits in a warehouse in these big open bins in China for four or five years more than that, before it finally makes its way over to the US or gets included in a product. The herbs that I use in my practice are sourced in a really different way. One of the companies I use is in Marin county and they try to use as many fresh, organic, wild crafted, local, herbs as they can. And the herbs that they do get from China they get from the number one supplier that complies with all of the regulations and they’ve been over to visit the factory. Obviously you’re gonna pay more for those kind of herbs but for me it’s worth it because I know that they work and they’re way more potent than herbs that have ben out of the ground for ten years and sitting in a bin in a factory, and they’re also safer.

DANNY RODDY: That Natural Calm news you posted was sobering.

CHRIS KRESSER: Yeah and to be fair there were a lot of good comments and responses to that, I think that article that I came across was a little bit old, like two years old, and the founder of the company has responded to it and said that they comply with the regulations and so there is confusion about that too. Sometimes there can be scares that people make more of a big deal of something than should actually be made. But certainly it does highlight the importance of going with a brand that’s really trustworthy or with the case of herbs I think it’s generally fairly safe to use single herbs in relatively low doses depending on the herb, but when you start getting into formulas and when you start getting into using herbs for therapeutic purposes it’s really best to find an herbalist to work with because you absolutely can cause problems and damage with herbs.

So let’s get into some questions.

Can vasectomies can contribute to early onset Andropause?

DANNY RODDY: Cool, okay this one’s from Andrew this is off your Facebook page, he asks if vasectomies can contribute to early onset andropause.

CHRIS KRESSER: That’s a great question actually, and I did a little bit of research on this and I guess what we can say is the jury’s not out, but there is enough research to give me pause, if that was something I’m considering, which I’m not obviously. First of all let’s step back a little bit, I mean the idea that the vasectomy is totally safe is not quite accurate. As any man will testify the testicles are very delicate and sensitive structures. They’re complex organs with a really rich nerve and blood and lymph supply, and they’re under this intricate hormonal control that we’ve already talked about during the show. And also intricate temperature control that regulates sperm and testosterone because sperm has to be produced in a pretty narrow temperature range. And another thing is that the sperm is really tightly isolated from the rest of the body so that the man doesn’t produce antibodies to his own sperm, which as far as the rest of the body is concerned sperm is a foreign protein. So there are these defenses that keep the sperm isolated from the immune system. Now all of that, that intricate hormonal and temperature control, the defenses that keep sperm isolated, the delicate physiological structures can be disrupted even when the vasectomy seems to have gone well. And there can be short and long term complications which can be serious. So there’s a clinic, the Harley Street Clinic which is a place where they specialize in treating andropause and some of their own internal research, this isn’t double blind placebo controlled stuff it’s anecdotal but in their experience over the past ten years 25% of men who have come in for treatment for andropause have had a vasectomy. And that’s about twice the level in the general population. And in some of the surveys they’ve done, 35% of men who have filled out this andropause checklist and had andropause have reported a vasectomy in the past and some sister impotence clinics in Australia that they work with have reported a rate as high as 45%. So we don’t know for sure what the mechanism is there but one of the theories is autoimmunity related to sperm released into the tissues after the vasectomy. In other words that defensive structure that keeps the sperm away from the immune system is disrupted and then the immune system becomes aware of the sperm and treats it like a foreign protein, starts producing antibodies to it and then that becomes sort of an immunological time bomb. So to summarize, we don’t know for absolute sure that a vasectomy can increase the risk of andropause but there certainly is some evidence suggesting that it does and there are some clinical studies above and beyond the anecdotal studies that I mentioned that have shown increase in anti-sperm antibodies shortly after a vasectomy in animal studies and there’s been a couple studies that have shown an increase in LH levels after a vasectomy which could indicate a compromised ability to produce testosterone. And then there’s been some other studies about general increase in autoimmunity after that surgery. Anytime you have a surgery like that there’s a risk, and so I think it’s real, but what the likelihood of something happening is not entirely clear.

DANNY RODDY: Yeah I won’t be getting a vasectomy any time soon.

CHRIS KRESSER: Some people, I have no judgement for the choice that people make in that regard but just be aware that there is some risk.

The blood and saliva markers for Andropause

DANNY RODDY: Totally. This one’s from Martin I think we kinda went over this but if you could give the quick, dirty rundown of the blood markers that you look for, that you’re concerned with, with regards to andropause.

CHRIS KRESSER: Well actually I prefer saliva testing for hormones because it’s cheaper to test the free hormone levels that way and you know we mentioned before that you can test either the protein bound hormones to see what’s happening with the glandular production or you can test the free hormones to see what’s actually active in the tissues. With blood testing you can test both free and protein bound hormones but the free hormone testing with blood is quite expensive. And saliva hormone you test free hormones only and it’s much more affordable so I use a saliva hormone panel in my practice. There are a couple different labs that offer it, there’s Biohealth diagnostics and Diagnostechs so I test for the steroid hormones, the sex hormones like testosterone, dihydrotestosterone, I always test for estrogen in men too, to see if they’re over converting, that can tell us about aromatization. I test for androsteindione which is a precursor hormone so it’s important to know about that. And then when I’m doing a male hormone panel I always run cortisol and DHEA because those are the primary stress hormones and DHEA being a precursor hormone to the stress hormones and sex hormones. We can find out more about what’s happening with the adrenals and how much stress is contributing to the picture, so I usually do a complete hormone panel. Of course in terms of blood work and basic stuff you can test your blood sugar, so you can test fasting glucose, a1c, and fructosamine. And then you can also do post meal blood sugar testing with a glucometer to determine whether insulin resistance is an issue. Uric acid’s another kind of surrogate marker of insulin resistance and blood sugar regulation. And then in terms of inflammation you can test for acute phase reactants like ferratin and c-reactive protein. And in terms of autoimmunity I might look at a CBC, look at a white blood cell count. And you can look for anti-sperm antibodies if there’s evidence that might be happening.

DANNY RODDY: That should definitely get the whole picture, doing all of those.

CHRIS KRESSER: Exactly.

What role libido/erections play in determining health?

DANNY RODDY: This one’s from Darius, if/when the body is healing what role does libido/erections play in determining health. When/how does the body divert sexual and reproductive energy into healing? Are andropause ever a good sign? And just to emphasize what do you think, is morning erections a good sign of testosterone production?

CHRIS KRESSER: I don’t actually know, do you?

DANNY RODDY: I mean from personal experience I know libido is always higher when that phenomenon is happening. I used to talk to this anti-aging doctor and he was super hot on that being a positive sign.

CHRIS KRESSER: It makes sense but I’ve just never seen any studies about morning erections being a marker for testosterone, I haven’t looked that carefully either. I think I understand what he’s asking, which is essentially will the body divert resources that would otherwise go into production of male hormones into healing in a chronic illness state.

DANNY RODDY: Probably pretty hard to tell.

CHRIS KRESSER: Yeah I think it probably does though, because you’ve got like I mentioned before the precursors pregnenolone, 17-hydroxytprogesterone and DHEA, and there’s something called the pregnenolone steal, where pregnenolone is diverted into cortisol production and away from the sex hormone pathway which would go into DHEA and down through the rest of the sex hormones that way. So what you see often in a lab panel in the pregnenolone steal is high levels of cortisol and low levels of DHEA and low levels of the sex hormones and cortisol is one of the major anti-inflammatory hormones. So let’s say you’ve got some kind of chronic illness going that involves an inflammatory component which almost all chronic illness does, then you might see increased production of cortisol in order to deal with that inflammation and that would divert precursor material and pregnenolone into that pathway and away from the male reproductive pathway. Conceivably also if you have blood sugar issues like hypoglycemia or reactive hypoglycemia that then cause chronic cortisol secretions to bring blood sugar back up, that could conceivably divert pregnenolone into that cortisol pathway rather than the male reproductive pathway so yeah I think it’s definitely possible. In terms of whether andropause symptoms are a good sign of healing I don’t know if we could go that far. I think it’s more of a sign that the body is in a state that is where it doesn’t have enough resources for both the stress tolerance and the production of male hormones so I would  interpret it more as a sign of being in a healing state, and needing more healing rather than being a good sign of healing.

Should Andropause be accepted as part of normal, physiological decline of males?

DANNY RODDY: Okay the next question is from Greg, should andropause be accepted as part of normal, physiological decline of males, or do our lifestyle choices influence this to any great degree positively or negatively.

CHRIS KRESSER: I do think that there is almost certainly a normal, slight decline in testosterone production as we age, but andropause implies to me kind of a pathological acceleration of that process. So I don’t think andropause is necessarily normal, but I do think that some decline in testosterone production as we age is normal. In terms of the second part of the question I absolutely think that lifestyle choices influence to a great degree and I think we’ve covered that extensively. Things like stress management, making sure you get enough sleep, reducing inflammation, improving your glucose tolerance and insulin sensitivity, are all definitely lifestyle related. And so that can play a really significant role in how we age and whether we experience andropause or not as men.

Is a “beer belly” and are “man boobs” signs of Andropause?

DANNY RODDY: I like this next question, I have a friend who is approaching 50, he has a beer belly, or a gluten belly, and what he refers to as man boobs. He is a major workaholic stress monster and fears his mortality and fears the loss of the use of his manhood. I’ve heard it said that belly and boobs are indicators of too much estrogen. Is he bringing on his andropause at an alarming rate by not treating himself better? Where should he start to repair what he has done to himself? Perhaps he needs to stop by your office.

CHRIS KRESSER: Yes. Beer belly, wheat belly, gluten belly, and man boobs can all be signs of estrogen dominance in a male particularly the man boobs. Wheat belly or beer belly could be a sign of visceral fat accumulation due to increased cortisol levels or insulin resistance or both. But man boobs are pretty sure characteristic sign of estrogen dominance.

DANNY RODDY: I think hyperprolactinemia also causes that?

CHRIS KRESSER: Yeah that’s another potential cause for sure. But hyperprolactinemia can cause hypergonadism, which would cause estrogen dominance so yeah. He is probably bringing on andropause by not treating himself better.  I would say a food toxin free diet like a paleo template type of approach making sure to reduce processed and refined grains, and seed oils and soy and eating plenty of healthy saturated fat, we’re not gonna talk about macronutrient ratio because we know by now that there are many different macronutrient ratios for different people right? And then probably stress reduction is gonna be the major factor for this guy, workaholic stress monster does not seem like a good…

DANNY RODDY: What about fears mortality and the use of his manhood.

CHRIS KRESSER: So certainly stress management. I work pretty hard and I work a lot right now, but I do make an effort to, I’m still able to fit it in and even if it’s five or ten minutes a day that can have a really profound effect. Being too busy is not an excuse, it’s not one that really holds water anyways. Or put another way yeah, fine if you say you’re too busy for stress reduction then you’re just gonna have to deal with the consequences of it. And I don’t say that without compassion I just day you gotta make time for it. I think everyone can find five or ten extra minutes in a day and I still haven’t found anyone that’s so, so busy that there aren’t five or ten minutes that they spend extra on facebook or twitter, something else that they couldn’t spend just sitting in a chair closing their eyes and doing five or ten minutes of stress reduction.

DANNY RODDY: But now they’re all gonna be google +ing.

CHRIS KRESSER: Anybody have an invite? Please, please. That’s all I need is a whole other thing like that. Anyways who knows maybe Google + will be the best thing since sliced bread and I’ll be all over it but I doubt it. So that’s it I think that’s the last of our questions huh.

DANNY RODDY: Yeah great episode, awesome. I really enjoyed it.

CHRIS KRESSER: Yeah it was fun, and we always love to hear your feedback and questions so you can post them when we post this blog post, in the comments section. I’ll probably be changing dirty diapers at that point in the middle of the night so I may not be able to answer immediately but eventually I’ll try to get to them.

DANNY RODDY: Chris where can we find more of your work on the internet this week?

CHRIS KRESSER: Thehealthyskeptic.org, I’m in the middle of a series on natural child birth, just wrote the first article which looked at the mistaken idea that hospital birth is safer than home birth and I’ve got a few other articles planned in that series which I may get to the next one before the baby comes or I may not. Also healthybabycode.com if you’re interested in nutrition for fertility, pregnancy, and breastfeeding, and that’s about it.

DANNY RODDY: You can find all my work at Dannyroddy.com. Keep sending us your questions at thehealthyskeptic.org using the podcast submission link. If you enjoy listening to this podcast head over to itunes and leave us a review. Thanks for listening guys.

CHRIS KRESSER: Thanks everybody.

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Comments Join the Conversation

  1. Jim C. says

    As someone happily on TRT for 5 years, I found this episode quite fair and informative.

    I always wondered about vasecomties potentially causing problems and I will skip getting one done.

    The 24 hour urine test from Rhein Labs can also be helpful in seeing what is happening over the course of a day.

  2. J says

    Well, I’ve forwarded this page to my “stress monster” friend. Perhaps he’ll listen.

    Thanks for the words of wisdom along with a dose of humor.

  3. LeonRover says

    Thank you for your podcast — most interesting.

    You gave me the impression that testosterone cream provides testosterone to tissues only in free form – that is not bound to SHBG.
    I did not get this impression from studies concerning transdermal patches published in Testosterone – Activity Deficiency Action – Ed Nieschlag & Behre 2nd Edition 1998 (Springer).

    I would be gratetful for any references you could make available.

  4. darius sohei says

    thanks for talking about my question!
    i have noticed that during times of stress, being busy, healing from an injury, etc, that i will have symptoms of andropause – sometimes long (weeks) bouts with little desire for sexuality – that will abruptly go away when things are healed “enough”. it is a strange phenomena mainly because indulging these returning urges will sometimes put me in a state of stress again such as being overly tired, irritable, moody, etc. so it seems like “enough” isn’t actually enough, but that the body wants what it wants regardless of the consequences for me.

  5. says

    Great post. But I wonder how many of men would actually want to talk about this in detail – especially as this is still considered a taboo phase in sexual health related information worldwide.

  6. Dan B says

    Any chance you will do a podcast on Type 1 diabetes and what you feel are the healthiest treatments for it? Maybe get Dr. Bernstein on the podcast or something of that nature?

  7. Bluprint says

    Can you point to the evidence you mention discussing risks of vasectomies? I would like to know more about this specific issue.

    Great show. Thanks.

  8. Mike D says

    As one who has only dial-up internet access, it would be great if a transcript of the podcast was available. Podcasts just don’t work on dial-up.

  9. Scott L says

    A very interesting podcast. I understand how supplementing with testosterone downregulates your own production via negative feedback. However, would supplementing with precursors such as pregnenolone have the same effect as the body can move it into whatever pathway it wants to ie. androgens or cortisol. Would this alleviate or exacerbate symptoms if someone was stressed and experiencing pregneolone steal type symptoms?

  10. says

    Hi Chris,

    I am 24 now and have been dealing with low testosterone since I was about 18. This was the same time my eating disorder hit a low point and my body fat was at about 1-2%. While I’m healthier now, my body fat is still very low and I am very hard training triathlete. For years the doctors couldn’t figure out what caused the low testosterone, but I had done a lot of research and thought it was from my body fat level. Finally I was able to see a specialist who said, yes, this was the case.
    My question is, can low body fat in fact shunt testosterone production? And is there a way I can reverse this??
    Thank you so much Chris

  11. Jorge says

    Hi Chris,
    Interesting episode!

    I didn’t catch the name of the place that sells the organic herbs you talked about.

    Cheers

  12. says

    Hi Chris,

    Interesting podcast – I’ve told my husband he needs to get more sleep – didn’t realise that 5-6 hours per night would reduce testosterone levels.

    I have a question about supplements – I recently attended a product training session for Neways products and one of the Naturopaths mentioned that she has used a product called Transfactor (http://www.neways.com.au/Products/Catalog/product.aspx?NQS=xW7G61Snws3pTrM8gPm0jWIw5s8x8eBW6sJElYKPoJU%3d) for her children to help improve gut integrity.
    The product contains bovine colostrum and maca – is it ok for me to give this to my 3 year old? The naturopath recommended emptying the contents of the capsule into a drink for easy ingestion.

    My son had eczema as a baby (from 5 months to about 20 months of age) he is still breastfeeding but he refuses all meat, vegetables and fruit and only eats toast, pasta, pancakes (homemade with eggs) and sometimes he will eat ham.

    Thanks for your help.

  13. Charles says

    Chris,
    I just had my hormones tested and my estradiol was high, 7 (with a range of 1-3pg/ml) as well as free T 105 (range of 40-70 pg/ml) and progesterone 288 (range 5-95pg/ml) Everything else was in the normal range. I’ve eaten low carb for the better part of 10 years and feel pretty good at age 47. Of course, I do carry extra weight in my hips/waist so I believe I need to take an AI to block the estrogen conversion.

    You mention chrysin as a aromatase inhibitor, but every place I look online people are saying that it doesn’t actually work in people, just in a petri dish. So, does it really work? And should one take it with bioperine? What about DIM? Is it better?

    Thanks in advance.

    • Jim says

      For right or wrong, I have been on injectable testosterone cypionate for almost 5 years. My testosterone is medically-prescribed and my serum tests are not over the normal lab range.
      Aside from the exogenous sourcing shutting down one’s system, I have seen some side effects. The biggest one is a slow increase in hematocrit/hemoglobin over the course of a year. Donating blood is one way to mitigate this problem. Testosterone can scavenge cholesterol. My LDL when down from 99 to 68 my first month, with the only change being the addition of the medication. My HDL has always been on the low side even before testosterone and I am working on bringing it up. I just had some tests done this week and don’t have the results back yet. Occasionally, one might have a little nipple sensitivity once every 6 months, even though the dosage has been consistent for years. I also try to use a 25 or 26g needle now as the 22g are too big for my taste and I don’t want scaring in the injection areas. As far as Blood Pressure, I have been as low as 104/60 but usually I am around 112/72-118/76.
      Nighttime/morning erections are the norm. Daytime ones are occasional. Libido can be increased and this may present a problem if your libido is substantially greater than your wife’s.
      I travel internationally for work and need to get import permits to bring the medication into Australia and the UK. The permitting process is easy plus in AU, they even have a special line for those declaring steroids and illegal drugs and often provide you with 3 customs officers to assist you in your entry : )
      Hope this helps….

  14. says

    @51min Dr Oz has said testosterone is highest in mornings and that attributes to morning erections.
    -
    What do you assess of this theory of aging (extrapolated to humans) … many say ‘eat for fertility’ for the optimal diet, but I have heard of this ‘pleiotropy theory of aging’:
    “This system is highly likely to remain the way it has evolved
    because of the antagonistic pleiotropy theory of aging, which asserts
    that selection for early reproductive success permits deleterious
    effects on fitness in later life because genes that are operative during
    development are also operative in later life, but exert different effects
    on health.26 Indeed, because the lack of negative feedback ensures
    maintenance of the drive to procreation mediated by testosterone,
    the present evolutionary state (without a mechanism of limiting
    free T) may already represent the desirable ultimate of evolution as
    far as propagation of the species is concerned.”
    (text is from ‘acne and cancer.pdf’: http://robbwolf.com/2011/09/13/the-paleo-solution-episode-97/#comment-47146)

    From wikipedia: “An antagonistically pleiotropic gene can be selected for if it has beneficial effects in early life while having its negative effects in later life because genes tend to have larger impacts on fitness in an organism’s prime than in their old age.[4] An example of this is testosterone levels in male humans. Higher levels of this hormone lead to increased fitness in early life, while causing decreased fitness in later life due to a higher risk for prostate cancer.[9] This is an example of antagonistic pleiotropy being an explanation for senescence. Senescence is the act of ageing in individuals; it’s the failure over time of the individual’s life processes by natural causes. [10] Williams’s theory has been the motivation for many of the experimental studies on the reasons for aging in the last 25 years.[11] However there is more than one theory out there for aging. The competing model to explain senescence is Medawar’s “mutation accumulation” hypothesis, saying that “over evolutionary time, late-acting mutations will accumulate at a much faster rate than early-acting mutation. These late-acting mutations will thus lead to declining viability and/or fertility as an organism ages.”[11] ” http://en.wikipedia.org/wiki/Antagonistic_pleiotropy_hypothesis & http://en.wikipedia.org/wiki/Evolution_of_ageing#Antagonistic_pleiotropy
    -
    And are phytoestrogens at all protective (upgregulation of gene expression antioxidants & oxidative stress, preventing telomere shortening?):
    http://is.gd/1FfhU9 ‘women men.pdf’ http://nutritionfacts.org/videos/mitochondrial-theory-of-aging/

  15. santiago says

    Hi Chris,

    I found this interview after some long search on the paleosphere on information about high estrogen in men. Needless to say, very helpful. I think I’m in case 4 of your description, high testosterone and high estrogen. I have high estrogen and I’ve become worried about this. No problems with sugar, and diet is pretty paleo with no apparent inflammation. However I’ve been using finisteride for some years for hair loss, that I’ve stopped after realizing of the potential serious side effects.

    According to my pattern what should I look into, inhibit aromatization with chrysin?. I’ve been reading about DIM and I3C supplements, but no sure about the side effects.

    Thanks.

    ** Testosterone: 9.4 ng/ml (blood analysis)
    ** Estrogen (17beta-estradiol ): 56.6 pg/ml (blood analysis)

    Diet: mostly Paleo (version: zero grains, very little starches and some dairy)
    Age: 37
    BF: 14-15% according to my balance. Appearance slim.
    Fasting insulin: 3.7
    A1C: 5.4
    hs CRP: 0.037
    rheumatoid factor: 10.3

  16. says

    Hi Chris,
    I have a question or would like to discuss this reference/ topic testosterone and other hormone replacement (Episode 12 )I was frustrated after hearing your comments. I was going to start taking (HRT) hormone replacement therapy (Crème) because my testosterone has dropped considerably 239
    ng/dl My doctor wanted to give me the real thing ( steroids) but I told him NO thanks due to the side effects. Therefore, I would like to see what his suggestions are? or alternatives.? Lets talk please!
    sabresciences.com )
    Thank you very much for your reply and help!
    Sincerely,
    -Anthony (NJ) Age: Just turned 53
    PS. Side notes: Athletic, I’ve been training and eating healthy for
    the past 28 years, don’t smoke, don’t drink, All vitals are in great
    shape, heart, liver, all organs, etc, etc,
    Regular yearly Dr. check ups good, blood work, endocrinologist visit
    good, urologist visit good, prostate good,
    just my T has gone down. Go figure! I’ve just been dealing with a lot
    of stress though over the past 3 years.

  17. May Peterson says

    Hi,

    I wonder why other people who had vasectomies had an early onset of andropause. In our case it was different. My husband also had a vasectomy but it was not accompanied by any other behavioral or physiological symptoms except the fact that there isn’t an associated risk of a pregnancy. For several years, everything went fine for us. I didn’t know about those having vasectomies would have lower testosterone levels. Then, when we already decided to have a baby, we had the vasectomy reversed. If that was the common problem (having low testosterone levels), then I guess we were among the lucky ones because several months after the reversal I was able to conceive. Perhaps, it also had something to do with getting a good doctor to do the reversal, who in our case was Dr. Wilson ( http://www.microvasreversal.com ) and he was a Christian which was why he only charged $1700 for the procedure. So after having conceived, I tend to disagree that vasectomy would lower the testosterone levels, for sure, it was not the case with my husband. Maybe, we or my husband was a special case, I don’t know. The only thing I can say is that it worked for us.

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