The debate about low T has dramatically accelerated in the 2 weeks since the NYTimes published “Don’t Ask Your Doctor About Low T.”
The day after, the NY Times published an editorial of its own, calling on regulators “to strengthen warning labels and find ways to rein in the industry’s promotional efforts.”
In medicine, the Endocrine Society has called for better research, and Harvard, Johns Hopkins and Medscape have all published essays to help physicians become aware of the problem.
Contributors to the LA Times, Huffington Post, Yahoo Health, Fox News, NPR, EveryDay Health and many other commentators have weighed in. The FDA is still weighing the evidence about elevated heart disease risk with prescription medication.
At least 4 testosterone lawsuits have been filed in Illinois “on behalf of men who were allegedly injured by Androgel.”
Of course Stephen Colbert was way ahead of this game.
But what has been missing, at least to my reading, is a FAQ about low T and erectile dysfunction, and what can men do about both. Below are some of the questions I’ve received recently, and some short answers.
Incidentally, the firestorm facilitated by the Op-Ed and really caused by the onslaught of direct to consumer advertising for prescription medication (primarily Androgel) has led doctors to complain that every man who is fatigued wants to be tested.
Most doctors I’ve spoken with are wary and not eager to prescribe, as so many side effects are worrisome.
I think patient requests for testing for low T leads to overtesting. For physicians, it is much easier to go along with a patient’s request than to investigate the common causes of fatigue.
But if “low T” questions raise the subjects of diet, exercise, stress control and sleep in the medical office, then that has the potential to be of real benefit to men.
And to the women who often helped them get to see the doctor in the first place.
20 FAQ about Low T and ED
1. How do men make T?
Men’s testicles’ Leydig cells convert cholesterol into testosterone. Cholesterol is the building block of testosterone.
2. Do I need to eat more cholesterol to make more T?
No. Your liver makes all the cholesterol you need to make T. And food rich in saturated fat raises cholesterol levels…not food rich in cholesterol.
3. Should I eat more fat to make more T?
Whole foods which are fatty are probably preferable to sugary, starchy foods, which increase appetite in men, and increase insulin resistance, making it harder to lose belly fat. Fatty foods are not the enemy for men…as long as they are not deep fried, battered, breaded, highly processed cheese sticks, onion rings, french fries, and so on.
4. Which foods have more saturated fat?
Whole milk cheeses, egg yolks, coconut and palm oil, butter and dark chocolate are good sources of saturated fat. Though saturated fat raises cholesterol levels in most people, it probably does not cause heart disease in modest amounts. Saturated fat foods are also highly satiating.
5. Do statins, used to lower cholesterol, also lower testosterone levels?
Yes, likely. In laboratory studies statins inhibit testosterone production (Reproductive Toxicology, Jan. 22, 2014). It seems that this might contribute to ED.
6. What is the definition of low T?
The medical definition is not settled. Before the onset of advertising for the “disease-awareness campaign”, physicians identified it as a very low level (200 or less) and a history of a cause such as trauma, undescended testis, radiotherapy, or brain lesion.).
Over the past few years, some physicians now feel that is a symptom diagnosis (fatigue, low energy, low sex drive, low muscle mass, depression, anxiety); others feel that is is a total testosterone level of less than 300 or 350 plus symptoms. The Endocrine Society definition, which conforms to this, is contained here.
7. Is low T the same as hypogonadism?
No, it’s not. Low T is, at best, a laboratory measurement. Hypogonadism is a disease characterized by very low levels of the hormone because of genetic or pathological causes, usually a brain problem, or testicular radiotherapy, chemotherapy or trauma.
8. Is having low T a normal part of aging?
Possibly, but not certainly. It’s just as likely that conditions that often occur as men get older, such as obesity or depression, lower levels of testosterone. Testosterone levels decline in response to synthetic artificial chemicals, such as herbicides like atrazine, and prescription medication (like opiates), irrespective of age.
9. What is the definition of erectile dysfunction (ED)?
It is the inability to reach/maintain erection sufficient for satisfactory sex.
10. Does low T cause erectile dysfunction?
Probably not: low testosterone levels interfere with arousal and sex drive, not ordinarily actual performance. Erectile dysfunction, while surprisingly common, is usually a blood flow problem more than a hormone problem.
11. Is ED an actual medical problem?
Yes it is. It is equivalent to smoking, hyperlipidemia, and family history of MI as a risk factor for CVD. Men in their 40s with ED have 50x the incidence of new-incident coronary artery disease than those without ED. If you’re 40 and have ED, get a stress test. Now.
12. Does ED predict heart attacks?
Often, yes, especially in diabetic men. Heart attacks occur when a coronary artery is suddenly blocked, and coronary arteries are 3 to 4 mm in diameter. Penile arteries are generally half that size, or smaller.
13. If a doctor tells me I have low T, what should I do?
Your doctor should test you at least twice, in the early morning, because the level of testosterone varies up to 30% from one morning to the next; and because a lower level does not absolutely correlate with symptoms.
Unless you have hypogonadism (see above), I would try diet, exercise, stress and sleep improvement before taking any prescription medication, or over the counter supplements. I would certainly ask for a careful description of the potential side effects of the medication, including interaction with other medications.
14. How do I test my own testosterone levels?
15. Why might taking testosterone cause heart attacks?
Testosterone raises blood pressure, which puts pressure on coronary arteries. It also causes an increase in red blood cell count, and in platelet aggregation, which impede blood flow. And it lowers HDL, or healthy cholesterol, which repairs artery walls after they have been damaged by LDL or lousy cholesterol.
16. Should I avoid prescription testosterone?
Most men don’t need it. Men with elevated PSA (prostate) tests or a history of prostate or breast cancer; with high red blood counts; and with a history of heart disease should not take testosterone.
Men who want to remain fertile should know that taking prescription testosterone usually shuts off your own supply, and reduces sperm counts.
17. What if I can get prescription testosterone without having my level measured?
Don’t do it. But unfortunately, this is very common: in one study, “fatigue” was the second most common diagnosis of men who received testosterone, without measuring their level! Having excess T should accelerate risk for heart problems.
Men with too high levels of testosterone have a weaker immune response, as measured by a boost in protective antibodies after vaccination against influenza, than do men with lower testosterone levels and women, according to recent Stanford studies.
18. How do I raise my testosterone level without taking drugs?
The most successful ways are
- lose belly fat (because the enzyme aromatase from fat cells converts testosterone into estrogen, raising your estrogen level and lowering your testosterone simultaneously).
- improve your vitamin D level (measure it first, here: men who take their level from 40 to 50 improve their testosterone level by as much a 15%).
- get enough zinc (but not too much: more than 30 milligrams daily suppresses immune function: you want just 15 milligrams: take it as a supplement, or eat your oysters
- sleep more than six hours each night: men who sleep less have levels 10-15% lower than men you sleep 6-9. Aim for 7 hours minimum.
19. Do exercises help elevate T?
Yes, high intensity interval training gives you a boost in testosterone level. I illustrate resistance exercise in REFUEL.
20. What foods help erectile dysfunction?
The traditional Mediterranean diet has been shown to improve erectile function, morning erections and sexual performance. But rather than focusing on a particular food or for that matter resistance exercise, it’s more efficient to think of food as fuel, and refocus with the right tools, tactics and a program you can stick to.
If you have more questions about testosterone, ED, food, fitness, sleep and stress, feel free to post them here, or email me with them, and I’ll do my best to answer them.