Updated: Feb 12
Testosterone is a hormone that affects many physiological processes in the body that includes sex drive, erectile function, vascular and heart health, mental health, lipid parameters, bone density and body mass to name a few. Defined by the endocrine society low testosterone is a “clinical syndrome” that is representative of the testicles inability to produce physiological levels of testosterone and symptoms.
Symptoms of low testosterone include:
reduced sex drive
loss of muscle mass, obesity
reduced energy and endurance
loss of body hair, reduced beard growth
weight gain, bone fractures
fatigue & reduced motivation
depression & poor memory
The criteria for the diagnosis of late-onset hypogonadism, also known as Low-T, is a patient must present with both symptoms of low testosterone and low testosterone blood levels. In the research literature hypogonadism is defined many ways, but all have commonalities of both symptoms and low testosterone levels. The European Male Aging Study (EMAS) proposed the criteria for hypogonadism of at least 3 sexual symptoms accompanied by low testosterone level less than 11nmol/L and free testosterone levels less than 220 pmol/L. Another study by Harman et al defined low testosterone as circulating testosterone less than 325ng/dL.
Using these criteria for defining low testosterone approximately 3%-8% of men in the United States between the age of 20-45 have androgen deficiency. Testosterone decreases in men after age 30, 1% each year. Treatment of testosterone deficiency in men is accomplished by the administration of exogenous testosterone. Although testosterone replacement therapy has benefits of improved sexual function, cognition, muscle strength, lean body mass, bone strength and improves cardiovascular health there are associated side effects. Such side effects can include erythrocytosis, accelerated prostate growth, male infertility, testicular atrophy, and gynecomastia.
Given the necessity of being on lifelong testosterone therapy to reverse the symptoms of low testosterone many patients do seek alternative methods. There are a variety of alternative medical and natural methods patients can undertake to improve the symptoms of low testosterone that are safe, preserve fertility and have a lower side effect profile than exogenous testosterone therapy.
These alternatives to testosterone therapy include HCG, aromatase inhibitors, select estrogen receptor modulators, stress relief, sleep, diet, nutrition and weight loss.
Human Chorionic Gonadotropin (HCG)
Human Chorionic Gonadotropin (HCG) is hormone derived from the female placenta that mimics the actions of luteinizing hormone (LH). LH is normally produced by the pituitary gland to stimulate the testicular Leydig cells to produce testosterone. HCG has a similar effect on the testicular Leydig cells raising testosterone levels. There are a variety of studies that have demonstrated exogenous HCG administration can increase testosterone in males. In 2011 Kim et al demonstrated that administration of 1500 to 2000 IU of HCG 3 times per week significantly improved testosterone levels. Vicari et al in 2012 further demonstrated 1,500 IU 3 times per week of HCG could increase testosterone levels significantly over a 24-month duration. Another benefit of HCG found in the study is the improved semen parameters in patients undergoing therapy. HCG stimulates not only testosterone production from Leydig cells but also enhances spermatogenesis. Thus in men who desire to preserve fertility, maintain testicular size and raise testosterone levels, HCG can be a great option. In men who are taking testosterone, the addition of HCG 3 times per week, can maintain spermatogenesis, fertility and testicular size. Risks of HCG administration do include a headache and possible fatigue. Long-term data to support its efficacy and other side effects are lacking in publication.
Selective Estrogen Receptor Modulators (SERMs)
SERMs are oral medications that act to inhibit the estrogen receptor at the level of the pituitary and hypothalamus. Estrogen has an inhibitory effect on the pituitary to prevent the release of LH and FSH. LH and FSH stimulate the Leydig cells and Sertoli cells within the testicles to enhance spermatogenesis and produce testosterone. By preventing the inhibitory effect of estrogen on the pituitary with SERMs, gonadotropin release can be up-regulated. Several studies in men taking SERMs have been performed. In 2011 Katz et.al performed a prospective study that examined 86 men age 22-36 years of age with testosterone levels less than 300ng/dL. Patients received 25 to 50 mg of medication every other day for 19 months. Results revealed testosterone increase from 192 at baseline to 485. A study by Shabsigh et al. prospectively observed 36 Caucasian men who were administered 25mg of a SERM. Follow up visits at four and six weeks revealed a mean testosterone increase from 247ng/dL to 610ng/dL. SERMs have great oral bioavailability and are a great alternative for men who desire to boost testosterone levels and maintain fertility. It is a safe off-label alternative for men who are considering testosterone replacement therapy.
Aromatase Inhibitors (AIs)
AIs is an oral medication that inhibits the conversion of testosterone to estrogen. AIs act upon an enzyme called aromatase that is most prominent in the bodies peripheral tissues. The action of AIs reduces estradiol levels in men inhibiting the negative feedback of estradiol on the pituitary. This will, in turn, raise testosterone level production by the Leydig cells of the testicles. Treatment with AIs is considered off-label in men, yet several studies performed have detailed their beneficial effects as an alternative to testosterone therapy. A few side effects that have been reported with AIs include hot flashes, weight gain, insomnia, decreased bone mineral density. While taking AIs, estrogen and testosterone levels need to be monitored to tailor the medication dosage and duration for a patient to get the desired results.
Lifestyle: Diet, Exercise & Weight Loss
Men with late-onset hypogonadism will most commonly have 1 of 3 conditions that include: diabetes mellitus, metabolic syndrome, and obesity. Chronic medical conditions are a significant cause for hypogonadism. Improving comorbidities through healthy lifestyle changes can improve testosterone levels. Nondrug therapies are inexpensive yet very effective in boosting testosterone levels naturally and can be accomplished by healthy nutrition, exercise, obtaining adequate sleep and decreasing stress. A study by Kumagai et. al found that 44 obese men who performed a 12-week lifestyle modification program involving aerobic exercise three times per week and a diet limited to 1680 kcal/day increased their testosterone levels. Even in the absence of exercise, weight loss itself by way of eating healthy can induce a rise in testosterone levels. This was shown in 2013 in a study by Corona et al. They performed a meta-analysis review of 13 studies evaluating the effect of low-calorie diets. Their results found that weight loss achieved through diet or bariatric surgery was associated with increases in total testosterone. With to diets, the Mediterranean diet (low-fat dairy, eggs, poultry, fish, and vegetables) demonstrated improved total sperm counts.
A study by Corona et al. in 2006 demonstrated a linear relationship between the severity of metabolic syndrome (hypertension, increased waist circumference, and high blood sugar) and testosterone levels. Men with low testosterone levels are more likely to have components of metabolic syndrome. Men with metabolic syndrome were also found to have higher anxiety and stress levels that are pivotal to proper sexual function and a healthy libido.
Improvement in sleep quality and duration can improve testosterone levels in men. It has been shown that men with obstructive sleep apnea (OSA) not only have high rates of erectile dysfunction but also have lower testosterone levels. This was conveyed in a study by Santamaria et. al, in 1998 that prospectively observed 12 men with OSA who were treated with therapy (uvulopalatopharyngoplasty) and found at 3 months postoperatively to have increased testosterone levels.
Duration of sleep is also just as important as the quality of sleep to improve testosterone levels. Sleep deprivation (less than 5 hours per night) can decrease testosterone levels by 10-15% in men.
The bodies natural stress hormone is cortisol. Cortisol is secreted during times of stress and anxiety. Elevated cortisol levels can negatively impact the production of testosterone. One theory is that cortisol acts upon the Leydig cells of the testis to inhibit the natural steroidogenic pathway for testosterone production. Stress management has been studied as means to improve testosterone levels and improve health and mental clarity. Studies have found that majority of men where stress was a common factor in their lifestyle had the following attributes: held 1 or more jobs, worked 50-60 hours per week, long commutes to work and were held to deadline and work quotas. Reducing these lifestyle factors can improve testosterone levels in men.
In conclusion, there are a variety of methods men can undertake to increase their testosterone levels from prescription medication to lifestyle changes. Each individual patient who desires to be on testosterone replacement therapy must first be evaluated by a physician to ascertain the cause of low testosterone. Without making the right diagnosis, the correct treatment cannot be administered successfully. Second, each patient is different. Each patient has a desired goal and expectation of therapy that must be discussed with the physician prior to starting therapy. Testosterone replacement is not for everyone and there are alternatives mentioned above. At REGENX Health we ensure all our patients meet with a physician and all options of therapy are discussed. We discuss every patient’s goals and expectation of therapy and their desire for fertility. To schedule a consultation with a REGENX Health Urologist please give us a call or visit us at www.REGENXHEALTH.com. You can also submit questions through our online physician request form for more information.
Stay tuned for our next article to improve your health and wellbeing.