by Dr. Amir Farid Isahak
The male sex hormones are collectively called androgens, of which testosterone is the most important, although there are others that work in tandem with it. They play their important roles right from early foetal growth, through childhood, youth, adulthood, and old age.
In each stage, there can be problems due to low or high androgen levels.
Male Foetal Development
In the womb, the foetus begins with female external genitals, and in the male, androgens influence the development of the male genitalia from the neutral female form.
However, sometimes the cells fail to respond, and the female external genitalia persist. The male child will be born as a female baby, and will grow up as a normal girl, and the problem is realised only when she fails to menstruate even when she has become a woman.
When examined, she will be found to have a vagina, but no womb or ovaries. Instead, she has testicles which remain in the pelvis. This is the fascinating 'testicular feminising syndrome', when a genetic male has a normal female external form.
She can have sexual intercourse, but will never menstruate nor bear children.
Because the undescended testes are prone to cancer, they are usually removed and she is treated with female sex hormones instead.
Conversely, some female babies are born with an enlarged clitoris due to excessive androgen stimulation.
In the past, some hormone injections used to prevent miscarriages had androgenic effects, which could cause virilisation of the foetuses, but these are not used anymore. Fortunately, the cases of foetal feminisation or virilisation are rare.
Male Puberty and Adulthood
During childhood, the androgen levels are low until the child reaches puberty, when the surge in hormones cause hoarseness of the voice; growth of pubic and armpit hair; moustache (and later beard); enlargement of the penis and testicles; acne; and a gradual emergence of male sexual behaviour (sexual awareness and urges).
Except for children with certain chromosomal abnormalities which affect their masculinity (e.g. those with Klinefelter's syndrome, who have XXY chromosomes instead of XY, small testicles and penises, and are usually infertile), most boys and young men do not face much problems with their male sex hormones until they reach their 40s.
Thereafter, due to poor diet and lifestyle, and especially due to the lack of weight-bearing exercises (which make muscles grow), their androgen levels decline. Some younger men are subfertile or infertile (due to low sperm production, abnormal sperm or blocked sperm duct).
Male Middle-age and Andropause
For a long time, it was thought that there was no significant decline in testosterone that could explain the decline in libido and sexual performance of most men as they reach 40, and certainly when they reach 50.
Now we know that while the total testosterone levels may decline only slightly, the decline in free testosterone (i.e. that is available to act on the cells) is significant.
Testosterone that is bound to the carrier protein (called sex-hormone binding globulin, SHBG) is not active. The decline in the free hormone is largely due to an increase in SHBG.
So the myth that andropause (male menopause, also called PADAM – partial androgen deficiency in ageing men) does not exist was shattered.
Note that the age for andropause is about the same as for menopause in women (average 50-51 years). The health assessment of the male above 40 is therefore not complete without checking the free testosterone level.
Several years ago, male doctors attending an anti-ageing seminar (in Kuala Lumpur) were tested for their testosterone levels. Their age range was between 35 to 55. Many were found to have low (total) testosterone levels, and many also had excess estradiol (the main female sex hormone).
If free testosterone was tested, probably three-quarters or more would have low levels, because free testosterone levels are often low even when the total testosterone levels are normal.
In my clinic, about 90% of men above 50 have low free testosterone levels, with some having extremely low levels! No wonder many men are complaining of poor libido, and poor sexual performance, especially if they are also unhealthy, unfit, obese, and worse of all, if they are diabetic.
Many are totally dependent on drugs like Viagra every time they want to have sex. But these drugs only work on about 70% of them. The rest suffer in silence. Yet, if they have their hormones corrected, and their health status improved, they can still hope for some recovery of their sexual function.
Testosterone for Total Health
While the young boy needs sufficient HGH to grow, after puberty, healthy levels of both the androgens and HGH are needed. The effects of both hormones overlap in many areas (eg. fat loss, increases muscle bulk, bone growth, strength, mental health, improved immunity, etc.), but the androgens are more specific in promoting the masculine features (male hair distribution, testicular and penile growth, and sexuality).
Even the skin depends on good levels of these hormones. Note that a variant of testosterone (dihydrotestosterone, DHT) is responsible for male-pattern baldness while testosterone itself promotes hair growth.
The main complaint of men above 50 is erectile dysfunction (inability to achieve and maintain a good erection). The other health problems are quite similar to menopausal women, except that men get osteoporosis (brittle bones) 10 years later than women because they start off with stronger bones.
You can help your body maintain healthy testosterone levels by doing adequate exercise, especially the muscle-building workouts. You should eat more proteins – fish, meat and eggs. Sufficient saturated fats (excess is unhealthy) are required, so don't throw away the egg yolk!
Cut down coffee, cigarettes and alcohol; and wear loose underwear to ensure that your testicles are always cooler than the body.
These are hormones that stimulate the testicular cells to multiply, differentiate and mature. Certain testicular cells produce testosterone. The gonadotropins (FSH and LH) are produced in the pituitary gland (in the middle of the brain). Some of the cases of testosterone deficiency are due to gonadotropin deficiency. In such cases, gonadotropin therapy is preferred since this will stimulate the normal functioning of the testicles, instead of just getting the testosterone from external sources.
However, in the usual situation, the decline of androgens associated with andropause/ageing results in high levels of gonadotropins, as the brain attempts to push the exhausted testicles to work harder to produce testosterone. In women, the same scenario is seen in menopause, with the gonadotropins trying to stimulate the exhausted ovaries to work harder.
If your free testosterone level is low, your doctor may recommend therapy to optimise the level. Some doctors only treat when the level falls below the normal range, but anti-ageing and sports medicine doctors treat those who have low-normal levels to bring them up to average or high-normal levels to achieve optimum health.
From my experience, maintaining high-normal levels improves the patients' overall health, energy, sexual life, and many other aspects of life.
There are many forms of testosterone (or their analogues/variants) available. The most convenient are tablets or capsules. There is even the sublingual form (available overseas). From my experience, these do not work very well. The earlier formulations also had the risk of stressing the liver.
Testosterone cream, gel or transdermal patches are probably the best and safest method because liver modulation is avoided, thus high doses are not necessary, and liver stress is avoided. The disadvantage is the need to apply daily as a routine.
For convenience, injections are available that need to be given only weekly to three-monthly periods, depending on the testosterone variant used, and the severity of the deficiency.
Finally, there is the implant form that can last up to 6 months. Your doctor should also regularly monitor the levels to ascertain that the desired levels are achieved.
The combination of HGH and testosterone (or DHT) can help increase the size of the penis in men who have a small penis (medical term is penile hypotrophy or micropenis). Combining HGH with HCG can help increase testicular size and sperm production.
Testosterone is converted to estradiol in the body through a process called aromatisation. Many men have excess estradiol due to excess conversion, and one sign of this is gynaecomastia (breast development in men, with enlarged breast tissue). Gynaecosmastia may also be caused by certain drugs, and alcoholic liver disease. It should be distinguished from enlarged breasts due solely to fat accumulation (pseudo-gynaecomastia). Many boys and men suffer from these problems.
Both cases need dietary changes and androgen therapy. For gynaecomastia, DHT gel is applied to the breast, testosterone and HGH may be injected, and an enzyme blocker is used to prevent excessive aromatisation. If caused by drugs, then these should be stopped, and alternative drugs should be used. If the cause is excessive androgens (and hence excessive conversion), as may happen in body-builders who are known to take high doses of androgens, then estradiol-receptor blockers may be added to reduce the stimulation by the excess estradiol.
Those with pseudo-gynaecomastia need to lose weight, eat more meat, and build muscles. Hormone therapy is similar, since fat accumulation there also means testosterone and DHT are lacking. Severe cases can be treated by liposuction for immediate results.
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