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Low Testosterone Integrative Approaches

What is Testosterone Deficiency (TD)?

Testosterone is the main male hormone (“androgen”) responsible for development and maintenance of male characteristics and sperm production.

If your body is not producing enough testosterone, it can lead to a decrease in energy, sex drive, strength, and many other symptoms.

Low testosterone may also be referred to as testosterone deficiency or hypogonadism.

Prevalence

The Global Prevalence of TD Ranges From 10 40%

Testosterone production in men begins to decline in middle age, with significantly low levels present in up to 20% of all men over age 70. Low levels may affect as many as 7% of younger men as well.

Conditions in which low testosterone is prevalent.

  • Chronic opioid use for pain: 74%
  • Obesity: 52%
  • Diabetes: 50%
  • AIDS (HIV): 30%
  • Hypertension: 42%
  • Hyperlipidemia: 40%
  • Erectile Dysfunction: 19%

Signs & Symptoms

The testosterone starts to decline 0.3% to 1.5% per year from the 20’s/30’s. The signs and symptoms of low testosterone can be broad and overlap with many other medical conditions. The most common symptoms are:

Decrease in:

  • Energy and/or mood
  • Exercise tolerance
  • Ability to develop muscle.
  • Ability to lose fat tissue.
  • Concentration and/or memory
  • Sex drive or libido
  • Strength
  • Increase in body weight or fat.
  • Absence of morning or nighttime erections

In extremely low cases:

  • Hot flashes
  • Decrease in body hair (distribution or growth)

Risk Factors

There are many potential causes of low testosterone, however it can also occur without explanation.

Testosterone naturally decreases with age. Men in their 70s or older have a higher chance of developing it than men in their 40s or younger.

  • Trauma or injuries to the testicles, Infection to the testicles called orchitis.
  • Hypertension
  • Cardiovascular disease
  • Nutritional deficiencies
  • Insulin Resistance
  • Type 2 diabetes
  • Obesity
  • Stress
  • Toxicity
  • Metabolic syndrome
  • Chronic kidney disease
  • Chemotherapy can be toxic to Leydig cells directly.
  • Alcohol abuse
  • Obesity or being overweight.
  • Obstructive sleep apnea
  • Poor sleep or shift work.
  • Some medications: Opioids, glucocorticoids, cimetidine, tricyclic antidepressants,
  • nicotine, cannabis, Anabolic androgenic steroid supplementation, Statin drugs implicated but effect often nominal.
  • Major histocompatibility complex (MHC) full negative

Diagnosis

Low testosterone is diagnosed through a combination of blood testing and related symptoms. In Canadian labs, the normal testosterone range is between 8.5 – 29.5 units.

Low testosterone is diagnosed by a physician through a blood test and a review of symptoms. The actual lab number that represents “normal” covers an enormous range and so must be linked to the presence/absence of symptoms when considering if treatment is required.

Tips to keep in mind:

  • Check in early morning (7- 10 AM) serum total T.
  • Additional tests to Total T to include on confirmatory draw: free T, SHBG, Prolactin, LH, & FSH, CBC, PSA, ALT, to determine if the cause is primary or secondary hypogonadism.
  • The Serum testosterone levels in AM with men < 45 years of age due to diurnal variations is important! Late afternoon T may be 20-50% lower than morning T in young men.
  • Ideally 8 hours since last meal
  • Ideally 24 hours since last significant stress or sexual activity
  • Avoid testing if: Acute Illness, malnutrition, or on certain medications that reduce testosterone temporarily.
  • Measurement may need to wait until after patient recovers or stops medications.

Imaging: MRI or CT scans may be used to evaluate pituitary abnormalities

Prevention

  • Get Active: Exercise can help improve and maintain the natural production of testosterone. An increase in muscle and a decrease in body fat and overall weight helps you maintain normal levels. Aim to work your way up to 30 minutes of resistance training three times per week.
  • Eat Healthier: Eating an anti-inflammatory diet and maintaining a healthy body weight are important to produce testosterone. Aim for less ultra-processed foods like cakes, cookies, and chips, and add in more vegetables, fruits, lean proteins, and whole grains.
  • Sleep Better: Getting a regular, good night’s sleep can help prevent low testosterone and has been associated with better testosterone production. Aim for 7-9 hours of sleep per night.
  • Drink Less: Drinking heavy amounts of alcohol has been associated with lower testosterone production.

Treatment

Conventional Treatments

Testosterone Replacement Therapy (TRT): Administered via injections, patches, gels, or pellets to restore normal levels. Benefits include improved libido, mood, muscle mass, and bone density. However, TRT may have side effects such as acne, sleep apnea, male pattern hair loss, fluid retention and increased risk of cardiovascular issues.

Testosterone therapy is typically lifelong. It will stop sperm production and therefore is not administered to men trying to start a family.

 Potential Problems with Prescribing TRT

  • Cost
  • High rate of discontinuance
  • Potential Risks Any treatment needs to be carefully monitored.

Potential Risks of TRT

  • Acne
  • Apnea
  • Decrease in HDL to LDL (good to bad cholesterol) ratio
  • Depression (Can help as well)
  • Edema due to fluid and

electrolytes retention

  • Increased or decreased libido
  • Non infectious Hepatitis
  • Psychological issues
  • Polycythemia stop if HCT 54 or higher
  • DVT/PE data shows more a permissive association
  • Insomnia
  • Liver cell tumors 1st gen oral meds
  • Male pattern baldness
  • Nausea/Vomiting
  • Bladder irritability
  • Gynecomastia
  • Increased frequency of erection
  • Inhibition of testicular function infertility (azo or
  • Testicular atrophy
  • UNKNOWN RISK OF CVD ESPECIALLY > 65 y/o
  • Associated with both increased risk of DM2 and Breast Cancer (Bca) in women

Urology Consult Required When:

  • Abnormal DRE
  • PSA > 4 at anytime
  • PSA increase > 1.4 over a 12-month period after initiating therapy
  • Worsening Lower Urinary Tract Symptoms (LUTS).
  • Does not cause prostate cancer

Integrative & Holistic Approaches

Lifestyle Modifications and Mind-Body Therapies

If you have modestly low testosterone, a healthy lifestyle that includes regular exercise, good sleep, and a healthy diet is recommended to promote natural testosterone production and to maintain healthy body weight. Suboptimal testosterone levels may be amenable to lifestyle interventions.

  1. Sleep: Ensuring 7–9 hours of quality sleep per night is crucial for hormonal balance.
  2. Stress Management: Practices like meditation, yoga, and deep breathing can reduce stress-induced hormonal imbalances.
  3. Exercise: For instance, Regular physical activity, especially resistance and high-intensity interval training, can boost testosterone levels high-intensity interval training has been found to increase free testosterone in older, sedentary men, as well as experts’ athletes. In addition, a 2022 systematic review found that exercise training of any intensity increased basal levels of testosterone in older adults.
  4. Nutrition: A balanced diet rich in whole foods, healthy fats, and adequate protein supports hormone production. In addition to exercise, nutritional interventions that focus on natural aromatase inhibitors and 5-alpha reductase inhibitors may be appropriate in personalized treatment interventions. The two enzymes, aromatase and 5-alpha reductase, affect the conversion of testosterone to estrogen and the conversion of testosterone to dihydrotestosterone, respectively. Modulating these enzymes may therefore impact the levels of testosterone and estrogens circulating in the body. Studies indicate that a range of nutrients, from vitamins to herbs to flavonoids, affect these enzymes.
  5. Reduce Alcohol consumption. Studies also suggest that alcohol consumption may reduce circulating concentrations of total testosterone.

Foods, Herbs, Vitamins, Minerals and Supplements:

Certain nutrients are essential for testosterone production and hormonal balance.

  1. Vitamin D: Essential for testosterone production; deficiency is linked to low levels.
  2. Zinc: participates in the production of testosterone. Additionally, zinc is important for maintaining sperm quality as well. Always remember Copper.
  3. DHEA: A precursor hormone that can convert into testosterone.
  4. Quercetin and Grape Seed Extract: These compounds may inhibit aromatase, an enzyme that converts testosterone to estrogen, thereby supporting higher testosterone levels.
  5. Krill-Astaxanthin: Astaxanthin, a xanthophyll carotenoid, is the most abundant carotenoid in marine organisms and is one of the most powerful natural compounds with remarkable antioxidant properties and potential effects on inflammation that may indirectly contribute to improved hormone balance.
  6. Magnesium: Plays a role in hormone regulation; adequate intake supports testosterone levels. Low magnesium levels are associated with lowered testosterone and studies have found that supplements can help return testosterone levels to normal if the cause of the decrease is a deficiency.
  7. One study showed that taking supplements for at least a month may increase testosterone in all people, although people who exercise would see a more significant increase in testosterone levels than those who don’t.
  8. Vitamin B6: Involved in androgen production; deficiency may lead to decreased testosterone.
  9. Selenium the toxic effects of cadmium on the testes is ameliorated by Selenium.
  10. Vitamin A: the Vitamin A can improve testicular volume, regulates germ cell differentiation.
  11. Iodine: Iodine deficiency can contribute to low testosterone levels because it can lead to hypothyroidism, which disrupts the hormonal balance in the body, affecting testosterone production. Hypothyroidism can also decrease the amount of sex hormone-binding globulin (SHBG) in the blood, further reducing the amount of free testosterone available.
  12. Iron: Iron deficiency can negatively affect the production of testosterone. This is because iron is a crucial component of enzymes involved in testosterone biosynthesis, and a deficiency can disrupt this process. It can also impair spermatogenesis, the process of producing sperm, further impacting male reproductive health and can affect testicular function, potentially leading to reduced testosterone levels.
  13. Omega 3 fish oil: According to a study both EPA and DHA decreased levels of Sex Hormone Binding Globulin (SHBG) in middle aged and elderly men.

Aromatase Inhibitors

Aromatase is a key enzyme in the body which regulates the conversion of androgens to estrogens. When testosterone levels are low, or estrogen levels are high, lowering or inhibiting aromatase activity may help re-establish healthy hormone levels. There are several foods, herbs and supplements that may inhibit or lower aromatase activity.

Foods Associated with Lower Aromatase Activity

Dietary fiber

  • Flax seeds (lignans)
  • Soy (isoflavones)
  • Grape seed extract
  • White button mushrooms (Agaricus bisporus)
  • Green tea (Camellia sinensis)

Herbs Associated with Lower Aromatase Activity

  • Stinging nettle root (Urtica dioica)
  • Ginkgo (Ginkgo biloba)

Nutrients and Phytonutrients Associated with Lower Aromatase Activity

  • Quercetin
  • Vitamin C
  • Chrysin: Chrysin belongs to a class of chemicals called flavonoids. It occurs naturally in various plants and substances, such as the passionflower and honey
  • Zinc
  • Proanthocyanidins
  • Resveratrol
  • Melatonin
  • Dietary Fiber
  • Lignans from Flax seed
  • Isoflavones from Soy
  • Grape seed extract proanthocyanidins
  • White button mushroom
  • Green tea
  • Quercetin
  • Brown rice
  • Pumpkin seeds
  • Vitamin C
  • Stinging nettle root
  • Beta sitosterol Zinc
  • Chrysin (Passiflora incarnate) with Bioperine 500-1000 mg QD to BID

5 Alpha Reductase

5 Alpha reductase is a key enzyme in the body which regulates the conversion

of testosterone to a hormone called dihydrotestosterone (DHT). When

testosterone is converted to DHT, testosterone is lowered and can no longer

work effectively. This can result in conditions such as enlargement of the

prostate in men, hair loss in both men and women, and extra facial hair and

acne in women. There are several foods, herbs, and supplements that can be

used to inhibit or slow 5-α reductase activity and thus decrease or prevent

these symptoms.

Foods that Inhibit 5-α Reductase

  • Green tea
  • Flax seed (lignans)
  • Soy isoflavones
  • Fatty fish (omega-3 fats)
  • Pumpkin seeds

Herbs that Inhibit 5-α Reductase

  • Saw palmetto (Serenoa repens)
  • Stinging nettle root (Urtica dioica)
  • Chaste tree berry (Vitex agnus-castus)
  • Black cohosh (Actaea racemosa)
  • Pygeum (Pygeum Africanum)

Nutrients/Phytonutrients that Inhibit 5-α Reductase

  • Quercetin
  • Omega-3 fish oils
  • Krill (astaxanthin)
  • Beta-sitosterols
  • L-lysine
  • Rice bran
  • Finasteride, Finasteride, Dutasteride
  • Zinc
  • Progesterone

Sexual Hormone Binding Globulin (SHBG) Lowering

  • Boron

Homeopathic Remedies

Homeopathy aims to stimulate the body’s self-healing mechanisms. For testosterone deficiency, certain remedies are traditionally considered, though scientific evidence is limited:

  • Agnus Castus and Caladium: Often used for sexual weakness, decreased libido and erectile dysfunction.
  • Agnus Castus, Sabal Serrulata and Nuphar Luteum for Low Testosterone causing low Sex Drive.
  • Phosphoricum Acidum, Selenium, and Baryta Carb – For Low Testosterone causing Hair Loss
  • Kali Phos and Avena Sativa for Low Testosterone that Causes Low Energy
  • Argentum Nitricum – nervousness, inability to achieve erection, sweet and salty food cravings.
  • Baryta Carbonica indicated for impotence, reduced libido.
  • Lycopodium: Indicated for erectile dysfunction and low confidence.
  • Nuphar Luteum Q – loss of sexual desire, relaxed genitals, involuntary stool, and urination emissions may be present.
  • Nux Vomica: Considered for stress-related hormonal imbalances.
  • Sabal Serrulata – lack of sex drive, testicular atrophy
  • Testis Suis: A sarcode remedy derived from animal testicular tissue, used to support testicular function.

Tissue Salts (Schuessler Salts)

Tissue salts are minerals that were first used in homeopathic medicine by Dr. Wilhelm Schuessler in the 19th century. Tissue salts are micro-doses of mineral salts believed to support cellular function.

  • Calc Phos (Calcium Phosphate): Supports bone health and vitality.
  • Ferrum Phos (Iron Phosphate): Aids in oxygenation and energy levels and is anti inflammatory.
  • Kali Phos (Potassium Phosphate): Addresses nervous exhaustion and stress.

Aryuvedic and Herbal Approach

Ayurveda identifies the importance of balancing Vata, Pitta, and Kapha doshas to ensure overall health, including hormonal balance.

  • Tribulus Terrestris: Traditionally used to enhance libido. The researchers from a study found that Total Testosterone concentrations were significantly higher in the Tribulus group after 3 months of treatment.
  • Maca Root: May improve sexual desire without affecting testosterone levels.
  • Fenugreek extracts have previously been shown to increase free testosterone hormone levels in older men with androgen decline and reduce physical symptoms associated with hypogonadism [43]. Similarly, 600 mg fenugreek extracts increased testosterone hormone levels from the baseline value.
  • Ashwagandha (Withania somnifera) is an herb used in Ayurvedic medicine to promote youthful vigor, enhance muscle strength and endurance, and improve overall health. In a study they concluded that the intake of a standardized ashwagandha extract for 8 weeks was associated with increased levels of DHEA-S and testosterone. Another study results showed that Ashwagandha inhibits the lipid peroxidation and protein carbonyl content and improves sperm count and motility as well as it also increased serum T and LH and reduced the levels of FSH and PRL.
  • Shilajit: A mineral-rich resin believed to enhance testosterone production and overall vitality.
  • Chrysin (Passiflora incarnate) Chrysin is a flavonoid extract found in honey and in Passiflora incarnate, or blue passionflowers. You can take chrysin in the form of tea or supplements. A 2012 study in rats showed that chrysin can increase sperm motility, sperm concentration, and testosterone levels.
  • Saw Palmetto It may help boost libido, increase sperm production, and improve symptoms of low Testosterone.

Conclusion

For men with suboptimal testosterone, addressing lifestyle considerations and nutritional interventions first is not only safe but may lead to the desired results. In addition, as with other hormonal imbalances, low testosterone may indicate a change in a patient’s overall physiology. Low testosterone levels or a testosterone deficiency diagnosis may be markers for the presence of an underlying physiological imbalance.

It’s important to approach testosterone deficiency with a comprehensive strategy that includes medical evaluation, especially since symptoms can overlap with other health conditions. Consulting with healthcare professionals ensures that any underlying issues are appropriately addressed and that chosen treatments are safe and effective.

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