One of my favorite things about being a healthcare provider is meeting the significant others of the patients in my practice. I’m grateful and humbled by any personal referral, but when someone entrusts me with the care of their beloved, I’m especially touched. In addition to the honor that this brings to me personally, taking care of couples helps me to understand the health dynamic within a family, and as a result I’m better equipped to help them make healthy changes.
The bulk of my practice is female focused, but I’m trained and experienced in caring for men, too. Often, at the end of a visit with a female patient, they’ll casually say, “I wish I could get my husband to come see you – he hasn’t seen a medical person in forever, and his XYZ is getting really bad.” I let them know that I’d be happy to see their partner, and that the door would be open when they were ready, without pressure or judgement. Sometimes I never hear from the partner, but often it’s a few months later that the call finally comes in. But, better late than never!
Many of the guys who come to see me have been out of medical care for years, or even decades. And it’s no surprise – studies show that men access healthcare at lower rates than women. The reasons behind this are unclear. We know men aren’t inherently healthier than women, so what is keeping them away? And how is this impacting the health of our communities?
When I was living and training in Brooklyn, NY, I looked up one day on the way to the subway to see a billboard advertising “Take Your Man to the Doctor” month. This public health initiative was started to urge men to get regular screenings, and to encourage their partners to take them in to get them. In an article about the event, Borough President Marty Markowitz said: “Take your man to the doctor — that means your husband, your father, your brother, your son, your uncle, your friend or your significant other. We don’t care how you do it. Nag him, drag him, cajole him, entice him — just get him to go. Remember, if you do, he will live to love you longer.”
I don’t know if this campaign is still running, but it speaks to the need to get more men engaged in the healthcare system. Perhaps we should have these billboards in every city around the country.
I see it as a major win when a male partner does finally make their way in to see me. Many are healthy, but some have underlying health issues that they’ve been ignoring for years. Many have symptoms that they have chalked up to stress or aging, but are actually dangerous conditions like diabetes or high blood pressure.
Hormonal Disruption in Men
One of the most common men’s health concerns that I see in my practice is low testosterone. Some men walk in suspecting that they have “low T” – they’ve seen the ads for testosterone-boosting meds and supplements and are eager to start something to boost their own. Others come in with more vague concerns – often mood changes and fatigue, not realizing that testosterone can be at the root of these symptoms as well.
Symptoms of low T may be subtle and can include the following:
- Low libido
- Loss of morning erections
- Depressed mood
- Weight gain (especially around the middle)
- Fatigue
- Irritability and decreased zest for life
- Loss of muscle mass
Meet Henry, an active 48 year old father and husband with a demanding job that requires an hour commute each way. The demands of his job make it a challenge for him to eat healthy – he’s often taking clients out to restaurants, and usually gets home after his family has eaten a healthy dinner. He buys his lunch at his office cafeteria, and relies on an energy drink mid-afternoon to keep him awake. He’s put on some weight in the past five years, mostly in his belly, and is finding it harder and harder to keep up with his kids when they run around outside. His legs ache at night and he has a hard time keeping them still. His interest in sex has waned, and he suspects it’s from his long days and high stress. He’s not as joyful as he used to be, but he figures that’s just part of getting older. He had his testosterone checked a few years ago, and was told that it was “normal”, but doesn’t remember what the values were, nor which tests were actually run. His wife urged him to come in because his leg movements are keeping her up at night (never mind his snoring!), and she’s read that Restless Leg Syndrome can be a sign of other medical problems.
As part of Henry’s workup, we ran some basic labs including tests for his blood sugar and insulin, hormones, thyroid, and nutrient levels. Henry’s labs revealed all sorts of interesting (yet not totally surprising) things. He was mildly anemic (which can cause Restless Leg Syndrome), pre-diabetic, deficient in vitamins D and B12, and had low normal testosterone. His estrogen level was elevated, and a sleep study confirmed sleep apnea.
An Integrative Approach to Men’s Hormones
In functional medicine, we are constantly seeking the root cause of symptoms. In the process, we sometimes find that there is a root cause to the root cause! We dig deep until we really get to the core, and then we start to heal from the inside out.
In Henry’s case, here’s what that looked like: poor diet and inactivity leading to pre-diabetes and nutrient deficiencies, as well as weight gain, which contributed to sleep apnea. Abnormal blood sugar, excess weight, and poor sleep/sleep apnea contribute to low testosterone. Low T affects red blood cell production and causes anemia, which in turn can cause restless leg syndrome. Restless leg syndrome complicates sleep even more which adds to weight gain, and that brings us back to where we started. The wheel keeps turning, in a vicious cycle. Luckily, Henry was motivated to make some changes and sought out help before things got out of control.
Why the Hormonal Havoc?
Henry’s not alone. Today’s modern man makes significantly less testosterone than his ancestors. Sperm counts have fallen by 50% in the US, Europe, Australia and New Zealand in the past four decades according to a recent study done by Hebrew University and Mount Sinai medical school. Fifty percent! That’s no small decrease. Why is this so?
It’s well-established that low testosterone is caused by obesity, blood sugar problems, chronic illnesses and infections, certain medications, alcohol use, sleep apnea, and testicular injury. We’ll dive into these root causes, and how to reverse them, soon.
There’s another less obvious cause of hormonal disruption in men. And it affects each and every one of the men in your life. Scientists are quite clear that endocrine disrupting compounds (EDCs) are at the root cause of the global epidemic of low testosterone. You may have read about EDCs in previous blog articles about how they affect female hormones. In short, EDCs are chemicals that bind to hormone receptors or mimic hormones in our bodies, having deleterious effects on our endocrine system. These chemicals are found in the foods that we eat, the products we put on our bodies, the plastics we keep our food in, and the stuff we clean our homes with. Some of the top offenders? BPA and phthalates – both found in plastics. We are exposed to these products day in and day out. We are learning more and more about how they affect our bodies and our hormones and believe that abnormal testosterone levels are at least partially a result of our exposure.
Recovering from Low Testosterone
So what do we do about low T levels? And are all men destined to suffer from hormonal deficiencies in our modern world?
Some men benefit from testosterone replacement, and there are several products on the market to help men with “low T” – injections, gels, and creams. When low T is due to andropause, the natural decline in testosterone production that comes with age (also referred to as “MANopause” – ha!), T replacement may be a good solution. Some young men go through andropause earlier than expected, and when other interventions don’t help to boost T levels, T replacement may be appropriate.
But for many men, low T can be dramatically improved with a few basic lifestyle changes. As you’ve learned from Henry’s story, low T is often a symptom of other issues, rather than a cause. If we can dig in and heal the underlying issues, hormones often come back in to balance. Here’s an overview of the most common testosterone tankers, and some recommendations for how to get things back in to hormonal harmony. For a printable toolkit of this information, click HERE.
Root cause #1: Obesity/overweight
The connection between obesity and low T boils down to the enzyme aromatase. Aromatase is an enzyme in our body that is responsible for converting testosterone into estrogen. Yes, you read that correctly – testosterone is turned into estrogen under the right conditions. Aromatase is made by both men and women, and has an important role in hormone regulation and balance. You may have heard about aromatase if someone you love has had breast cancer. Aromatase inhibitor medications are used to prevent the production of estrogens from testosterone so that estrogen driven cancers, like some breast cancers, are less likely to thrive. Aromatase is present in fat cells, so the more fat cells you have, the more aromatase is produced.
This is one reason that obese women have higher rates of estrogen driven cancers (1), and is also why overweight men have less testosterone – their fat cells are literally taking their testosterone and turning it in to estrogen. Visceral fat (the fat on the inside of your body, around your organs) is especially associated with low testosterone (2). So being “thin” isn’t necessarily an indicator of healthy testosterone levels. Many men are “skinny fat”, meaning that they may be a normal weight and appear lean, but they have unhealthy fat accumulation around their organs where you can’t see it, and this wrecks havoc on their hormones.
How do you know if you have excess visceral fat? In my office I use the InBody body composition scanner to measure visceral fat, as well as total body fat, muscle mass, body water, and basal metabolic rate. It’s a great tool for monitoring for changes “under the hood” – i.e. visceral fat – as you make lifestyle changes to improve your health.
Root Cause Rez:
Weight loss is a powerful, effective, and scientifically supported way to improve testosterone levels (3). There’s no secret to how to drop unhealthy pounds: nutritional changes and increased activity remain the best ways to improve body composition. Start with basic dietary changes – ditch the processed foods and sugar, including sugary drinks (sodas, energy drinks, sweetened coffee beverages), and limit or remove alcohol. Focus on a hormone-healthy diet that is full of vegetables, lean proteins, and healthy fats. Eat real, whole foods – foods that the earth provides for us and that our grandparents would recognize.
Root Cause #2: Endocrine Disrupting Chemicals (EDCs):
As you read above, EDCs are a major culprit when it comes to hormonal disarray. They can mimic estrogens, decrease testosterone levels, and interfere with hormone signalling. One study showed that even low levels of an herbicide called atrazine transformed male frogs into female frogs.
Root Cause Rez:
While it’s hard to avoid all EDCs, be mindful of the products that you put on your body, in your body, and anything that your body comes into contact with. The Environmental Working Group (EWG) has published their “dirty dozen” list of the top 12 EDCs and how to avoid them, and I encourage you to read this and make changes to decrease your exposure.
A few tips from the EWG:
- Check canned foods to be sure they aren’t lined with BPA, and/or switch to mainly fresh fruits/veggies!
- Consider using a water filter to avoid atrazine, a common contaminant of our water supply
- Avoid plastic food containers – switch to glass or stainless steel, instead
- Avoid personal care products that list “fragrance” as an ingredient – “fragrance” can include phthalates, a potent EDC. Beautycounter is my go-to for safer skincare and cleaner cosmetics, and they have a great line of men’s products!
- Avoid non-stick pans, as well as water resistant coatings on clothing, furniture, and carpets
- Buy organic produce when it’s appropriate – EWG’s guide to pesticides in produce is a great resource for which produce is best to buy organic
Root Cause #3: High blood sugar and insulin resistance
Another reason that obesity contributes to low testosterone is because of its association with high blood sugar and insulin resistance. Insulin resistance occurs when the body is given too much glucose (sugar), which triggers the release of insulin to help shuttle the glucose into our cells. When there’s too much sugar around chronically, our cells get tired of letting insulin in – they become resistant to the insulin, and more and more insulin is needed to get the job done. This causes excess insulin in the bloodstream. Insulin is known to trigger aromatase activity, and you now know what that means for testosterone levels!
Root Cause Rez:
Blood sugar balance is crucial for hormonal health as well as overall health and longevity. Dietary changes, like those mentioned in Root Cause Rez #1 help to balance blood sugar and promote healthy weight loss, which further helps with blood sugar regulation. Keep your intake of added sugars as low as possible. Ditch sodas, juices, energy drinks, and limit your intake of alcohol. While fruit provides lots of important nutrients, it also carries fructose along, which is a sugar. Limit fruit intake to two servings per day, and focus in lower glycemic fruits like berries.
Root Cause #4: Sedentary lifestyle
A lack of exercise can contribute to weight gain and low muscle mass, which we know contributes to lower testosterone levels.
Root Cause Rez:
Get moving! Exercise is a great way to boost testosterone. High intensity resistance exercise (like HIIT – high intensity interval training) is associated with elevated post-exercise testosterone concentrations (4). The key to staying active is finding an activity that you like, and sticking with it! Boot camp, kickboxing, and Crossfit all come to mind as great examples of HIIT activities that are fun and effective for muscle building. Interestingly, long-distance running has been associated with lower testosterone levels in men and women. So in this case it’s a sprint, not a marathon, that gets the results!
Root Cause #5: Insufficient sleep
Did you know that the majority of testosterone production occurs when you are sleeping? This is one reason that we check peak testosterone levels first thing in the morning (and why morning erections are a thing). So it follows that a lack of sleep can impact testosterone levels, right? Absolutely. A study of young healthy men published in the Journal of the American Medical Association in 2011 (5) found a 15% reduction in testosterone levels when these men were restricted to five hours of sleep per night, for just seven nights. Five hours of sleep is the average number of hours of sleep that is experienced by 15% of the workforce in the United States – on a nightly basis. So it’s no wonder that so many busy men are walking around with low T. Sleep apnea, a condition in which breathing is actually arrested for prolonged periods of time during sleep, is also associated with a significant drop in testosterone levels (6).
Root Cause Rez:
Get those Zs! I can’t tell you how many patients in my practice report getting less than the recommended 7-8 hours of sleep each night. For many, the culprit is staying up late to have some “me time” or time with their partner after all of the daily tasks are done. While this is certainly important, so is getting enough sleep. Aim for 7-8 hours per night. Shut off all screens at least 60 minutes before bed and give yourself some time to shift from “fight or flight” into “rest and repair” – implement a breathing or meditation routine, do some reading or journaling, have sex (also good for boosting testosterone!), or take a bath. If you suspect that you or your partner has sleep apnea, arrange for a sleep study through a local sleep center. Symptoms of sleep apnea include snoring, gasping for air during sleep, daytime sleepiness, high blood pressure, and difficulty losing weight.
Root Cause #5: Stress
Stress is known to increase aromatase activity, which in turn increase estrogen levels at the expense of testosterone (7). We also know that in times of high stress, higher levels of cortisol lead to higher glucose levels, and we’re back to the blood sugar dysregulation issue.
Root Cause Rez:
Do your best to reduce the stressors in your life that you have control over, and learn to cope with those that you don’t. Incorporate meditation and breathing into your day-to-day routine. Reach out for help if you are feeling overwhelmed. Remember that physical stress is just detrimental as emotional stress. Fuel your body with healthy foods, get sufficient sleep, and keep your blood sugar balanced.
Supplements to Support Hormone Balance in Men
Several supplements have been shown to increase testosterone levels in men, or help with the symptoms of low testosterone as you work on the lifestyle changes mentioned above. Here are a few to consider. As always, check with your healthcare provider before starting any new supplement – even “natural” products can have side effects, drug interactions, or adverse effects.
- Vitamin D: In a study of healthy but overweight men undergoing a weight loss program, those who were supplemented with vitamin D (3332iu/day) had higher testosterone levels one year later compared to controls who were not given vitamin D. Additional studies have supported the connection between vitamin insufficiency and low testosterone
- Dose: Base your dose on serum levels drawn by your healthcare practitioner with the goal of therapeutic levels >50
- Sources: (8) (9) (10)
- Maca root: While maca may not boost T levels, it has been shown to increase libido and improve mild erectile dysfunction
- Dose: 1500-3000mg/day
- Sources: (11) (12)
- Ashwagandha: This ancient herb has been shown to increase T levels in infertile, sedentary, and older men, and may also aid in anxiety and stress.
- Dose: 600mg per day, divided, with meals. Higher doses may be needed for fertility purposes
- Sources: (13) (14) (15)
- Fenugreek: Small studies have supported T boosting and libido improvement with this herb
- Dose: 500-600mg/day
- Sources: (16) (17)
- DHEA: DHEA, a hormonal precursor to testosterone and estrogen, can be given orally in supplement form and has been shown to increase testosterone levels in men 65 years and older
- Dose: 50mg daily
- Sources: (18) (19)
An important side note about supplementation and T levels – Licorice, when taken in supplement form, can decrease T levels, so be wary of using this for other conditions if your T is already low!
Wrapping Up
While low testosterone isn’t a life-threatening condition, it can certainly impair a man’s quality of life, self-esteem, and relationships. There are many natural ways to boost testosterone levels naturally, and I hope this article inspires you to take your health, and hormones, into your own hands!
For more information on men’s health and hormones, contact my office to set up a consultation. Dr Geo Espinosa is another amazing resource – he’s a men’s health naturopathic physician, and his website is full of great info!
References:
- https://www.ncbi.nlm.nih.gov/pubmed/28919302
- https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2265.2005.02299.x
- https://eje.bioscientifica.com/view/journals/eje/168/6/829.xml
- https://ec.bioscientifica.com/view/journals/ec/6/5/306.xml
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445839/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196059/
- https://www.sciencedirect.com/science/article/pii/S0303720711007441
- https://www.ncbi.nlm.nih.gov/pubmed/21154195
- https://www.ncbi.nlm.nih.gov/pubmed/22220644
- https://www.ncbi.nlm.nih.gov/pubmed/20050857
- https://www.ncbi.nlm.nih.gov/pubmed/12472620
- https://www.ncbi.nlm.nih.gov/pubmed/19781622
- https://www.ncbi.nlm.nih.gov/pubmed/19501822
- https://www.ncbi.nlm.nih.gov/pubmed/26609282
- https://www.ncbi.nlm.nih.gov/pubmed/30854916
- https://www.ncbi.nlm.nih.gov/pubmed/21312304
- https://www.ncbi.nlm.nih.gov/pubmed/21116018
- https://www.ncbi.nlm.nih.gov/pubmed/16487434
- https://www.ncbi.nlm.nih.gov/pubmed/16804050
