Nancy Onyett, FNP-C

Hormonal Effects of Male Obesity

In a prior blog "Male Andropause vs. Oxidative Stress Hypogonadism", I discussed the typical age  of men who are in andropause and younger men who are suffering from hypogonadism related to oxidative stress. In review of these two syndromes, both have similiar signs, symptoms, and a subtle onset. The end result in both syndromes is obesity.

In this blog I want to discuss the hormonal effects in male obesity. Obesity is largely due to stress, a poor diet, and lack of exercise. A poor lifestyle leads to oxidative changes within the body which causes insulin to rise in response to a poor dietary regimen. When insulin rises approximately midway there is unwanted weight gain usually in the abdomen first, then all over. Men, who have a family history of diabetes are at a higher risk of developing adult onset diabetes quicker than men who do not have a family history of diabetes. As a result, the insulin level rises as the body's tissues become resistant causing blood sugars to rise  above a normal range. Usually, the postpriandial blood sugar rises before the fasting blood sugar. Other metabolic  changes include an elevated LDL , triglycerides, and lowered HDL. Hypertension and hypothyroidism are other metabolic diseases that are manifested from oxidative changes within the body.

Testosterone is produced in the testes from FSH secreted from the pituitary gland.  In obese males with insulin resistance  a hormone disturbance  is created with lowered testosterone levels and elevated estradiol levels. The hormonal changes cause decreased metabolism, rising blood sugars, mood instability, lethargy, altered lipid levels,erectile dysfunction, infertility and decreased libido.  The physical and emotional symptoms are similar to the women's menopausal symptoms. A cycle of unwanted weight gain with carbohydrate craving  further complicate obesity and hypogonadism.

In young men who want to have children, the treatment is focused on a structured medical weight loss program. The insulin resistance is treated with a low glycemic diet and metformin. Also they are encouraged to start weight training which will enhance their natural testosterone and weight loss. Success in reversing the hormone imbalance depends on the patient's attitude to lose the weight. After six months of a structured weight loss program and no progress then HCG is offered at 500IU per day to start and titrated accordingly to the testosterone level. Once HCG is started it is not stopped or the testosterone level will drop and the estradiol level will rise contributing to weight gain and other previously mentioned symptoms. HCG stimulates the testes to make more testosterone which helps to lower  the estradiol level.

In older middle aged men, the difference in treatment is they can be started on compounded testerone cream, if they do not want more children. Also, they are started on a  weight loss program with metformin and if there is presence of cardiac risk factors  a stress test is done before exercise is prescribed. In the healthy older men a weighted exercise program is prescribed with a low glycemic diet to follow. The testosterone cream is weight based and titrated according to testosterone levels. If any other metabolic disturbances are diagnosed they are treated according to the standard of care such as hypertension, hypothyroidism,  and dyslipidemia with appropriate medications. 

All men on the medical weight loss program are seen every two weeks for evaluation. Other supplements include Vita-Cell B injections, B50 Complete, and Lap Band in a Bottle. The supplements, medications along with dietary restrictions and weighted exercise will enhance weight loss which corrects the hormonal disturbance.

Male Andropause vs. Oxidative Stress Hypoganidism

Quite often, I have young men in their 30's come to the office with complaints of sexual dysfunction along with decreasing energy. After a thorough workup MRI head for pituitary adenoma, ultrasound of scrotum for a varicocele, physical exam and blood work the finding more often than not is low testosterone levels. These young men are not athletes and most of them are in a relationship or married with children. The common theme presented is a stressful lifestyle financial, job security, and responsibility from family. Since the economic downturn I am seeing more of these men with sexual complaints; which inspires me to write a blog on the current research involving male menopause or hypogonadism.  When we discuss andropause it is often thought of occurring around 50 years old but current research shows oxidative stress on the body can start lowering the free testosterone in men past 35.

Andropause, also known as male androgen deficiency syndrome, is the male equivalent of female menopause.  It results from diminished levels of testosterone in the body, and exhibits a similar symptom complex to female menopause.

Testosterone is a hormone secreted by the ovaries, adrenal glands and testes.  It is the primary male sex hormone, responsible for male sexual development and critical in maintaining erectile function, libido, normal energy levels, and mood.  Testosterone also controls a whole range of physiological functions throughout the body.  Testosterone levels decline with age, beginning when a man is in his thirties.  By the age of 80 it is only 1/5 of what it was in youth.  In addition to aging, stress can also play a role in declining testosterone levels.  While the total testosterone does not drop drastically the free testosterone, which is the biologically active form, does decline significantly with age.  Increased estrogen levels (due to obesity, a high-fat diet, alcohol consumption, and low levels of serum zinc) and insulin resistance in men can further reduce free testosterone levels. 

The number of men in the U.S., between the ages of 45 and 70 years, is expected to increase from 46 million in 1990 to 81 million by 2020.  Currently more than 5 million men in the United States suffer from the effects of hypogonadism or low testosterone levels.   Because the drop in testosterone is more gradual the symptoms of andropause, male ‘menopause,’ appear over a longer period of time compared to the female menopause.  Symptoms present slowly, with a loss of overall energy, thinning bones and muscles, increased body fat, depression, and impaired sexual function.  Testosterone deficiency has also been linked to hypertension, obesity and increased risk of heart disease.   Men with heart attacks often have lower levels of testosterone and higher levels of estrogen.  Low free testosterone is an independent predictor of the degree of coronary artery disease in men.  Low testosterone is also a common characteristic in men suffering from heart failure.  Testosterone replacement has been shown to increase cardiac output in some men with congestive heart failure.

 One way to help maintain (if not actually increase) testosterone levels is by reducing excess body fat.  Weight-training is another way to raise testosterone levels in both males and females.  Additional lifestyle changes include avoiding excess alcohol and high-fat diets, increasing intake of soy products, taking caution with drugs which impair liver function, and managing stress.  Avoid over-the-counter agents promising to improve testosterone levels, such as androstenedione. 

In general, when natural testosterone is replenished for andropausal men it has the potential to prolong the quality-of-life by decreasing the diseases of aging.  Testosterone protects against cardiovascular disease; it can raise HDL cholesterol, and lower LDL cholesterol levels.  It may decrease blood pressure, excess body fat, and symptoms of arthritis.  Testosterone replacement stimulates the cardiovascular system, the neurologic system, muscles, and bones.  It may protect against Alzheimer’s dementia, type II diabetes, osteoporosis, muscle wasting, loss of libido and erectile function, inflammatory-related diseases and a range of cardiovascular diseases.

In these young men the criteria for their free testosterone to replace is under 170. The crucial question is do they want more children if not then testosterone therapy can be replaced. Once they are placed on the testosterone compounded cream, I check their free testosterone in one month and make adjustments accordingly. They are continually monitored for free testosterone levels and any associated comorbidities per case. Usually within the first month most of the symptoms disappear. The importance in testosterone replacement is to educate the person in signs/symptoms, side effects, application of the cream, and the physiological aging process their body is acquiring so that they can adopt a better lifestyle of nutrition and exercise both resistance and cardiopulmonary training.