Lately, advertisements for testosterone supplementation are filling the media. “Low-T” (low testosterone) has fast become a well-known term with advertisements that lead a man to believe that all his problems are instantly fixed simply with a testosterone supplement—universally oversimplifying a very complex issue. While testosterone is indeed an extremely important hormone for a man, it is but one component in a very complex body process.
Testosterone is one of the members of a family of hormones called the sex-steroid hormones. Other members include progesterone, dehydroepiandrosterone (DHEA), androstenediol, estriol, estrone, estradiol and dihydrotestosterone (DHT). The androgens (testosterone, androstenedione, DHT) affect mostly male characteristics while the estrogens affect mainly female characteristics. Others, like DHEA and progesterone, are precursors used by the body to build other hormones. In the past progesterone and estradiol were thought to be strictly female hormones but recent research indicates that the prostate is rich in hormone receptors and sensitive to the effects of all hormones in this family.
The body normally converts some testosterone to both DHT and estradiol. An excessively high testosterone level typically results in correspondingly high levels of DHT and estradiol, high values of which can exacerbate prostate enlargement, commonly known as benign prostate hyperplasia or BPH, and can also accelerate growth of an existing prostate tumor.
Hormones exist in two states: free (active) and bound (inactive). Only the free hormones attach to receptors on throughout the body to deliver their chemical message to the target organ. On average, approximately 97 to 98 percent of testosterone in a man’s body is inactive, circulating in the blood bound to a blood protein called Sex Hormone Binding Globulin (SHBG). The two to three percent remaining portion (free value) is actually the only bio-available testosterone left to act on the body’s receptors.
When testosterone is measured in blood, the bound and free values are combined into a single total value. In many cases, the ordering physician does not separately specify measurement of the free value, assuming that the body will convert the appropriate amount as needed. However, especially in older men, the conversion can be impaired due to an imbalance in related hormones, or illness, or medication. This is another reason why it is critically important to measure the full range of free values for at least five of the sex steroid hormones.
The range for free testosterone is typically calculated as a percentage of the total testosterone. But unfortunately, the reference range for total testosterone in blood (270-1100 ng/ml) is so wide that it becomes difficult to establish what is normal for a particular male. For example, an aging male with mid-range total testosterone might have extremely low conversion (less than one percent) to free testosterone. If only total is measured (the usual case), his deficiency will go unnoticed, and he will continue to have symptoms. A healthy percentage of free testosterone is between two and three percent, but many men feel better when their free value is a little higher. Since saliva hormone testing measures only free hormone values, guess work and calculations are removed.
All of the sex steroid hormones are interdependent. An artificially high value in one can cause others to skew off the normal in either direction. A good example of this often occurs with male body-builders who use large amounts of androgen hormones to aid in muscle building. A substantial portion of these excess hormones is converted to estrogens and DHT, resulting in unwanted breast growth (gynecomastia) and unwanted prostate growth (BPH).
This is why it is critically important to get hormone levels tested before attempting testosterone supplementation. Saliva testing is quick, private, and relatively inexpensive. Unlike blood testing, a saliva test measures only the critical free hormone levels. Most laboratories and many alternative health practitioners, recognizing the important interaction of hormones in the sex steroid family, recommend measuring free values of at least these five most critical hormones: progesterone, DHEA, testosterone, DHT and estradiol.
A practitioner can then review the results and if an imbalance indicates a need, supplementation can be instituted for one or more hormones. Thus, it is essential to test hormone levels before starting any replacement program and to retest periodically to make sure the values are staying within the appropriate range. When only a single hormone like testosterone is tested, there is no knowledge of the status of the others, and supplementing based on this limited information is definitely a prescription for disaster!
In the past, much of the medical literature warned against testosterone supplementation, under the belief that it would increase the risk of prostate cancer. Recent research has shown this to be untrue. There is no evidence that restoring a man’s testosterone level to its biological normal value will increase his risk of prostate cancer. In fact, many studies have determined the opposite. However, exceeding biological normal values can be very detrimental.
There are many different types of testosterone replacement therapies available. Most doctors use bi-weekly injections, but you can get transdermal patches, transdermal gels, implants embedded just under the skin that release the hormone over a long time period, and slow dissolving mouth patches. However, most of these methods use synthetic testosterone, and they have unwanted side effects that may tend to cause problems. The best way to use testosterone therapy is to use a bio-identical testosterone cream that is either prepackaged (Testim, Androgel) or mixed to your doctor’s prescription by a compounding pharmacy. The latter may be considerably less expensive. One of the advantages of the compounded cream is that the user can make minor adjustments to his dosage depending on how he feels.
Testosterone supplementation is indeed needed for many older men to bring levels back to a biological normal value. The keywords here are biological normal. Media advertising makes it seem like it testosterone supplementation is a harmless way to increase stamina, energy and sexual performance for any man. Nothing could be further from the truth. Excess testosterone—beyond a biological normal value—is linked to many serious medical conditions, most notably heart attack and stroke. With hormones, enough is good, but more is definitely counterproductive.