Posts Tagged ‘hormones’

Testosterone: Not Just For Men; Estrogen: Not Just For Women

October 5, 2013

Andrew Siegel MD Blog # 122

What’s going on with the unrelenting direct–to-consumer television advertising for medications?  On television and radio we are bombarded with ads for drugs for the “ABC” diseases—ED (erectile dysfunction), OAB (overactive bladder), low T (testosterone).  What’s all this hubbub about T (testosterone) anyway?  Why is T suddenly so special, so hot and trendy, the hormone de jour, the “new” Viagra?  Is this for real or mere media hype?

Medicine is truly in its “infancy” with respect to its understanding of the male and female sex hormones, testosterone (T) and estrogen (E), respectively. Not too long ago it was dogma that T was solely the male hormone and that E was solely the female hormone.  As is often the case in science, “dogma” turns to “dog crap” with time, research, and progressive understanding.

Dr. Joel Finkelstein, in the September 13, 2013 New England Journal of Medicine, disrupted the endocrine status quo and provided the scientific basis for the major importance of both T and E for male health and wellness (and there is little doubt that both E and T are also equally crucial for female health and wellness). His study clearly demonstrated that muscle size and strength are controlled by T; fat accumulation is primarily regulated by E; and sexual function is determined by both T and E.

Some basics about T:

In the life of the male embryo, T is first produced during the mid-first trimester, and this hormonal surge causes the male external genitalia (penis and scrotum) and internal genitalia (prostate, seminal vesicles, etc.) to develop. In the absence of T, the fetus becomes a female, making the female gender the “default” sex. Dihydrotestosterone (DHT) is the activated form of T required by the fetus to initiate the development of male physical characteristics. In the absence of DHT, male genitalia do not develop.  DHT is far more potent than T and is the hormone that also gives rise—much later in life—to male pattern baldness and the condition of benign prostate enlargement.

T is produced mostly in the testes, although the adrenal glands also manufacture a small amount. T has a critical role in male development and physical characteristics. It promotes tissue growth via protein synthesis, having “anabolic” effects including building of muscle mass, bone mass and strength, and “androgenic” (masculinizing) effects at the time of puberty.  With the T surge at puberty many changes occur: penis enlargement; development of an interest in sex; increased frequency of erections; pubic, axillary, facial, chest and leg hair; decrease in body fat and increase in muscle and bone mass, growth and strength; deepened voice and prominence of the Adam’s apple; occurrence of fertility; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and transition from “cute” baby face to “angular” adult face.  Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.

Thanks to the advertising of Big Pharma, patients now come to the office requesting—if not demanding—to know what their T levels are. Prescriptions for T have increased exponentially over the last five years, creating a $2 billion industry with numerous pharmaceutical companies competing for a piece of the lucrative T pie, as the cost of the product is minimal and the markup is prodigious.  Little did Butenandt and Hanisch—who earned the Nobel Prize in chemistry for their synthesis of testosterone from cholesterol way back in 1939—know of what their discovery would lead to 70 years later!

Who Knew? Humans manufacture T using cholesterol as a precursor, so don’t be under the delusion that all cholesterol is bad. However, don’t get carried away consuming cholesterol-laden foods reasoning that the Big Mac with cheese will raise your T.

T can bind to specialized receptors that are present in many cells in the body and exert numerous anabolic and androgenic effects; alternatively, T can be converted to 5-DHT  (the active form of T) or can be converted to estradiol—a form of E—by the chemical process of aromatization. More than 80% of E in men is derived from T as a source. When levels of T are low, there is a decline in E levels. E deficiency is important in terms of osteopenia (bone thinning) in both men and women.

Dr. Finkelstein’s study was really a more sophisticated and quantitative take on the original study by organic chemist Professor Fred Koch at the University of Chicago in 1927, this time using humans instead of animals, and quantitating the effect of the T replacement as opposed to a qualitative assessment. Professor Koch used capons—roosters castrated surgically (having their testes removed) at a young age.  He then injected them with a substance obtained from bull testicles—readily available from the Chicago stockyards—which essentially was T.   After injecting the capons with this extraction, the capons crowed like roosters, a feat that capons are incapable of.  When the study was repeated in castrated pigs and rats, the substance was found to re-masculinize them as well.  Unlike Professor Koch, who used surgically castrated animals, Dr. Finkelstein used humans who were temporarily “castrated” via a reversible medication.

In Dr. Finkelstein’s study, as reported in the NEJM, there were 2 groupings of 5 populations of men. Both groupings had their T production blocked chemically. One population was given no replacement T, another 1.25 grams T daily, another 2.5 grams T daily, another 5 grams T daily, and the last group 10 grams T daily. The average serum T and E levels of each population were the following: no testosterone replacement: 44/3.6; 1.25 grams: 191/7.9; 2.5 grams: 337/11.9; 5 grams: 470/18.2; 10 grams 805/33. The second grouping of 5 populations had their E blocked as well.  Testing was done to see the effects of T and E levels on lean mass, muscle size and strength, fat mass, and sexual function.

By looking at the aforementioned numbers, one can see a direct relationship between T dose and serum level of both T and E.  The higher the T dose, the greater is the serum T and E.  The study concluded that lean mass, muscle size and strength were T dose-dependent, meaning the higher the T, the more the lean mass, muscle size and strength.  Additionally, fat mass was seen to be E dose-dependent and sexual function was both T and E responsive.

Dr. Finkelstein concluded that E deficiency in men is a manifestation of severe T deficiency and is remediable by T replacement. Fat accumulation seems to occur with a mild T deficiency (T measurements in the 300-350 range); muscle mass and muscle strength are preserved until a more marked T deficiency (T <200) occurs.   E was shown to have a fundamentally important role in the regulation of body fat and sexual function and evidence from previous studies demonstrated a crucial role for E in bone metabolism. Therefore, low T is not just about low T, but is also about E deficiency, which is responsible for some of the key consequences of T deficiency. Measuring levels of E are helpful in assessing sexual dysfunction, bone loss, and fat accumulation in men with low T.

The amount of T made is regulated by the hypothalamus-pituitary-testicular axis, which acts like a thermostat to regulate the levels of T.  Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon. T levels can be low based upon testicular problems or hypothalamus/pituitary problems, although the problem most commonly is due to the aging testicle’s inability to manufacture sufficient levels of T.  T levels gradually decline—approximately a 1% decline each year after age 30—sometimes giving rise to symptoms.  These symptoms may include the following: fatigue; irritability; decreased cognitive abilities; depression; decreased libido; ED; ejaculatory dysfunction; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; and abnormal lipid profile. A simple way to think about the effect of low T is that it accelerates the aging process.

T is commonly prescribed for T deficiency when it becomes symptomatic. There are many means of testosterone replacement therapy (TRT).  Oral replacement is not used because of erratic absorption and liver toxicity. Injections are not the first-line means of TRT because of wide fluctuations in testosterone levels and injection site reactions. There are a number of testosterone gel formulations that are commonly used. There are also skin patches, pellets that are injected into the fatty tissue of the buttocks, and a formulation that is placed in the inner cheek or gum. Currently in the works is a long-acting injection.

Men on replacement T need to be followed carefully to ensure that the TRT is effective, adverse effects are minimal, and blood levels are in-range. Periodic digital rectal exams are important to check the prostate for enlargement and irregularities, and, in addition to T levels, other blood tests are obtained including a blood count and PSA (Prostate Specific Antigen).  Potential complications of TRT include acne and oily skin, increased hematocrit (thicker, richer blood), worsening of sleep apnea, hair loss, and suppression of fertility.

Bottom Line: T and E levels are of vital importance to men (as well as women), greatly impacting physical development, sexuality, mood, energy levels, etc. So while T advertisements may be annoying and confusing, it is wise nonetheless to assess and monitor T levels, particularly if one is experiencing any of the myriad of symptoms associated with low T.

Reference: “Gonadal Steroids and Body Composition, Strength, and Sexual Function in Men by Joel Finkelstein, M.D., et al:  ”The New England Journal of Medicine (September 12, 2013)

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health;  book is in press and will be available in e-book and paperback formats in November 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

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Healthy, Free and Natural Drugs

May 4, 2013

Blog # 105   Andrew Siegel, M.D.

Each and every one of us has the capacity to draw upon a powerful pharmacy housed within our bodies.  We are capable of producing and using to our benefit a powerful ‘cocktail’ of natural chemicals and hormones that can dramatically influence and affect our mood, energy, focus, drive, etc.

I am capable of tapping into my supply of  ‘happy drugs’ through the means of vigorous exercise. On my part it demands exertion, sweating, my heart pounding and heavy breathing—walking on the treadmill will not suffice for this purpose, even though any form of movement is certainly of benefit.   The ‘fix’ I get through physical exertion probably accounts for my ‘addiction’ to exercise and my suffering from ‘withdrawal’ if I miss my ‘dose’ for a day or two. It is not just the physical high that I get from this ‘drug’, but more importantly the emotional high that really keeps me coming back for more. Exercise is certainly not the means for everyone—we all need to try to figure out how to exploit our internal pharmacy that does not call for a doctor visit, prescription, co-pay or a medicine cabinet

Most days, I do not get the opportunity to exercise until after work, at 5PM or so.  On rare occasions, I will have a gap between early morning procedures and afternoon office hours, an interlude that affords me the opportunity to go home, exercise, shower and have lunch before returning to the office.  This past Wednesday, I had one such lovely day.  I began the day with a 7:30AM surgery at the hospital and because of the fact that I was finished by 10AM and did not have to return to the office until 12:30PM, I went home, changed, headed to the basement and pulled out one of my P90x plus DVDs, specifically the total body workout.  I exercised for an hour or so, and even though this particular workout was primarily resistance, I still worked up a great sweat and had my heart pumping and lungs heaving.  After a shower and a healthy lunch, I headed to the office, refreshed, renewed, restored and invigorated, feeling like the day was just beginning.

My office is hectic and stressful—especially since we started electronic medical records last summer.  That stated, on days in which I get to exercise midday, stress is banished.  I find myself super-alert, focused, energetic and immune from the many frustrations and irritations that typically chip away at my good spirits.  I am convinced that vigorous exercise releases a host of ‘happy drugs’ including dopamine, endogenous opiates and a cocktail of other natural chemicals that are responsible for my heightened state of mind, vigor, stamina, serenity and resistance to the usual stressors that typically leave me fatigued, depleted and emotionally and physically spent.

Because exercise makes me feel so physically and emotionally robust, I can better resist the urge to consume some of the junk foods that I am bombarded with at work. To wit, I had absolutely no urge to indulge in that piece of Dairy Queen chocolate ice cream cake that we had in the office. After my workout, shower and lunch, I truly had enough of a ‘high’ such that I did not need to get a sugar/fat/chocolate ‘high.’  Additionally, the thought process of ‘why blow the benefits of a great workout on an unnecessary indulgence?’ is very helpful in maintaining eating discipline.

I always vow that I must schedule exercise into my midday routine—for the benefit of myself as well as my patients— but I never do—the rare occasion it occurs is due to happenstance…and is a welcomed gift.

“Exercise is medicine, and every man needs a daily dose.”

Jordan Metzl, M.D.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Tapping Into Our Pharmacy Within

August 4, 2012

Blog # 69    Andrew Siegel, M.D.

We all have the capacity to tap into a powerful pharmacy housed within our physical beings.  Our bodies are incredibly engineered “machines” with an array of organs, tissues and cells that produce a cocktail of powerful natural chemicals and hormones that can dramatically influence and affect our mood, energy, focus, drive, etc.

I am capable of tapping my pharmacy within through vigorous exercise. It probably accounts for my “addiction” to exercise and my suffering from withdrawal symptoms if I miss a day or two.  Exercise is certainly not the means for everyone—we all need to try to discover own method for exploiting this robust pharmacy that does not demand a prescription, expense or medicine cabinet. Walking doesn’t cut it for me—I need to sweat, huff and puff and feel my heart pounding.

Most days, I do not get the opportunity to exercise until after work, at 5PM or so.  On rare occasions, I will have a gap between early morning procedures and afternoon office hours, an interlude that affords me the opportunity to actually go home, exercise, shower and have lunch before returning to the office.  Recently, I had one such lovely day.   I started the day with a 6:30AM procedure at the surgery center and because of the sheer efficiency of the facility, I was finished by 9AM, not having to return to the office until noon.  I went home, changed, headed to the basement and pulled out one of my P90x DVDs, specifically the back and biceps workout.  I exercised for an hour or so, and even though this particular workout was primarily resistance, I still worked up a good sweat and got my heart pumping and lungs heaving.  After a hot shower and a healthy lunch, I headed to the office, refreshed, renewed, restored and invigorated.

My office is hectic and office hours are often stressful.  However, on days in which I get to exercise midday, no one and nothing can “hurt” me.  I find myself super-alert, focused, energetic and immune from the many frustrations and irritations that typically chip away at my good spirits.  I am unequivocally convinced that vigorous exercise releases dopamine, endogenous opiates and a cocktail of internal chemicals that are responsible for my heightened state of mind, vigor, stamina, equanimity under pressure and resistance to the usual stressors that typically leave me fatigued, depleted and emotionally and physically spent.

I vow that I must schedule exercise into my midday routine—for the benefit of myself as well as my patients— but I never do, the rare occasion it occurs is due to happenstance.

“Exercise is medicine, and every man needs a daily dose.”

Jordan Metzl, M.D.

Andrew L. Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Available on Amazon Kindle

Losing Weight: Hard…Maintaining Weight Loss: Grueling!

January 7, 2012


 Blog #41  written by Andrew Siegel

Kudos to Tara Parker-Popes for her NY Times Magazine article entitled “The Fat Trap.” http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?_r=1&pagewanted=all

Bottom line: As we lose weight, our bodies change in terms of hormones and metabolism.  This biochemically-altered state persists after weight loss, spurring our appetite and ultimate renewed weight gain.  Thus, maintaining weight loss is an intense struggle in which we have to combat not only hunger and cravings, but also our body’s powerful internal drives.

After weight loss, ghrelin  (the hunger hormone that drives eating) rises from pre-weight loss levels, and leptin (the satiety hormone that suppresses hunger and increases metabolism) decreases from pre-weight loss levels.  Additionally, a number of other hormones associated with appetite and metabolism change and remain altered from pre-weight loss levels.  In essence, weight loss induces a unique metabolic state that causes a biochemical imperative to eat and regain weight.

Essentially, the body rebels against the weight loss long after the dieting has stopped.  This helps explain the sobering truth that once we become fat, most of us will remain fat. That stated, there are those who, in spite of biochemical forces that are obstacles, successfully achieve and maintain a normal weight after weight loss.

In addition to the internal biochemical imperative for weight gain after weight loss, our external environment aggravates the problem. We live in a culture where eating plays an enormously prominent role.  In our food-obsessed and food-centric society, it is very difficult, if not impossible, to avoid food cues and eating opportunities over the course of the day.  Our culture has reinforced using food for reasons that have no relationship to nutrition and energy, particularly when we eat for emotional reasons, ranging the gamut from reward-eating to stress-eating to boredom-eating.

Weight loss is not an easy task—we all know that pounds go on easily, but come off with great effort that involves fewer calories in and more calories out through exercise.  Many people are not successful at losing weight, although those who are truly disciplined can succeed.  Of those who do lose weight, most will ultimately regain the weight because of this combination of internal and external factors that conspire to thwart our best efforts.  These factors are so powerful that in order to overcome them to allow the weight loss to be permanent, a lifelong modification in our relationship with food must occur.  It is possible, but demands a dramatic change in mindset in order to resist our own internal biochemical imperative and the external “hostile” food environment.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com