Hey gentlemen.
Have you gained weight?
Is your wood as hard as it used to be?
Has a friend recommended a bra for better support?
Are you struggling to lose weight despite eating clean and exercising?
You may be suffering from an imbalance between testosterone and estrogen.
Testosterone has many functions in the male body, including: building muscle, strengthening bones, producing an erection and developing body hair. What happens when testosterone is deficient? Decreased energy, depressed mood, weight gain, decreased sex drive, erectile dysfunction, breast development and menopause-like hot flashes and sweats.
An Overweight Man Calls Me
Let's examine a common scenario in my private practice: an overweight man desires to lose weight. The first step is a complete metabolic, nutritional and hormonal work-up to identify any physiologic barriers to weight loss. These blood tests will help identify any issues requiring attention before implementing a nutrition and fitness plan.
One of these blood tests is Testosterone.
Normal T
The "normal" range for testosterone is quite large: 300ng/mL to 1200ng/mL. But what is the optimal range?
Optimal T: 500ng/mL to 1000 ng/mL
Below 500ng/mL, symptoms of testosterone deficiency can manifest
Above 1000ng/mL, symptoms of testosterone excess can manifest
So, I travel to his home in the morning (testosterone must be measured between 7AM to 11AM when levels are highest), draw his blood and drop off the specimen at Quest or LabCorp.
Unsurprisingly, the testosterone comes back low or low normal. Generally speaking, a level below 300 ng/dL is considered a testosterone deficiency. So, what's the problem?
Testosterone levels do not exist in isolation; testosterone is one of many sex hormones kept in delicate balance by your brain. In order to get a better understanding, let's review.
Sir Brain & Mr. Testicles
Do you remember Sir Brain and Mr. Testicles? Let's take a look at the conversation between these two organs.
The cycle starts with Sir Brain who releases Lutenizing Hormone [LH]. LH stimulates Mr. Testicles to release testosterone. Sir Brain detects levels of sex hormones in the blood and increases or decreases release of LH accordingly. Level of sex hormones too low? LH is increased. Level of sex hormones too high? LH is decreased. This mechanism of hormone regulation is called a feedback loop.
So, what's happening with our overweight man?
The only way to know is to measure his other sex hormones, too, including: LH, dihydrotestosterone [DHT], and estrogen [estrone and estradiol]. Only with a complete picture can we understand what's happening.
Dihydrotestosterone & Estrogen
A portion of testosterone will be converted into either DHT or estrogen [estrone & estradiol].
DHT plays an important role in development of body hair #beard #chestforrest. What happens when too much Testosterone is converted into DHT? Male pattern baldness. DHT predominance causes loss of hair on the head and repopulation of hair on the rest of the body. Generally speaking, men who have the thickest beards are more likely to be bald #hairbalance.
Why does this happen? Largely genetics. Some men have more of the enzyme [5-alpha reductase] that converts testosterone into dihydrotestosterone than others. The medication Propecia [finasteride] prevents balding by blocking the enzyme that converts testosterone into DHT.
Estrogen plays an important role in regulating libido and bone mineralization. What happens when too much testosterone is converted into estrogen? A man's worst nightmare: impaired erection, decreased sexual desire, development of breasts and weight gain. Weight gain is the more intriguing symptom of this list. Although a symptom of estrogen excess, weight gain can also cause estrogen excess. Let'e explore this chicken-or-egg situation.
The enzyme that converts testosterone into estrogen is called aromatase. Guess where aromatase is found? Fat cells. The more fat in the body, the more aromatase present, the more testosterone is converted into Estrogen. This testosterone/estrogen imbalance leads to a vicious cycle of weight gain.
Fixing the Testosterone/Estrogen Imbalance
In the case of our overweight man, his estrogen levels are high! His problem isn't testosterone production but rather testosterone conversion. He is converting an excessive amount of testosterone into estrogen in his fat tissue.
If excess fat is the problem, weight loss is the solution. But, if a high estrogen state is preventing weight loss, how can this cycle be broken?
Estrogen blockade! Arimidex [anastrozole] is an oral medication which blocks aromatase, thereby preventing conversion of testosterone into estrogen. Taking an estrogen blocker will decrease Estrogen levels while increasing testosterone levels. A higher testosterone state will facilitate fat elimination. Once excessive body fat has been eliminated, the estrogen blocker can be stopped.
Take an Estrogen blocker
Decrease estrogen and increase testosterone
Lose excess fat
Stop taking the Estrogen blocker
The only way to know your testosterone/estrogen balance is to get your blood levels measured.
Get Your Testosterone & Estrogen Levels Checked
without leaving home
Call Me 646.568.6636
Resources
Bendre, Sachin V. et al. "Clomiphene Citrate Effectively Increases Testosterone in Obese, Young, Hypogonadal Men" Reprod Syst Ex Disord. 2015 Dec; 4(4): 155.
Kim ED et al. "Oral enclomiphene citrate raises testosterone and preserves sperm counts in obese hypogonadal men, unlike topical testosterone: restoration instead of replacement" BJU Int. 2016 Apr;117(4):677-85.
Kovac, Jason R. "Reproductive endocrinology: Oral enclomiphene citrate in obese men with hypogonadism" Nature Reviews Urology 13, 133–134 (2016)
Mihalca R and S Fica. "The impact of obesity on the male reproductive axis" J Med Life. 2014 Jun 15; 7(2): 296–300.
Schulster, Michael et al. "The role of estradiol in male reproductive function" Asian J Androl. 2016 May-Jun; 18(3): 435–440.
Tan RB et al. "Clinical Use of Aromatase Inhibitors in Adult Males." Sex Med Rev. 2014 Apr;2(2):79-90.
Cover Photo: <https://www.theatlantic.com/health/archive/2011/11/excessive-body-fat-and-wider-waists-may-up-colon-cancer-risk/248706/>