Hello, hello, and welcome to today's podcast. Today we're staying on the personal track we've had going and talking about Mark's hormone journey from a male perspective.
One thing that's really interesting is that although men have always had the opportunity for testosterone replacement therapy, most men don't pursue it. And to get a diagnosis of hypogonadism, or low testosterone, a man has to have a testosterone level lower than 300 on two separate occasions — two separate draws — which is really very low. Symptoms often appear well before that. Most men we see in the 50-to-60 range come in with testosterone in the 400s, but men just never talk about hormones. It's always brushed off as, "Is it okay? Is it just part of getting old?" I can't tell you how many men have come into my office and told me, "I'm just getting older, it's part of aging."
We're not talking about all men today — we're talking about your experience, which is similar. I wasn't aware of the hormone imbalances I'd had for years; they simply became more noticeable to me after I replaced things.
Metabolic Markers Were the First Clue
When we first started down the hormone replacement path and got educated, your metabolic markers were the thing first noticed. For background: I've been an endurance athlete for the majority of my life, and I always tried to improve — run that mile or marathon a little faster. But as the years went, I kept slowing down and thought, "Well, that's just part of aging." I also didn't take the best care of what I ate then compared to now. I've still got room for improvement, but I'm way better now.
The metabolic markers we're referencing are A1C, glucose levels, inflammatory markers, and insulin levels. Those are a good gauge of what's really going on inside. They're the things that lead to weight gain, sluggishness, mood changes, fatigue, low endurance, and libido changes. That's where I found I had room for improvement. And very often, metabolic markers being off stems from lower testosterone or other hormone imbalances — thyroid insufficiency and DHEA. Those were the big ones for me.
One of the main differences between men's and women's hormonal change is that women's happens more rapidly and chaotically, while men's is very slow and steady — so it's less noticeable. Men think it's just fatigue and getting older, when it's actually part of a hormone imbalance that leads to other metabolic problems. Getting the labs drawn and seeing what was off was my wake-up call.
The other piece is that you didn't really feel like you had symptoms of hormone deficiency at first — it felt like "this is just how it is." I've always been motivated to exercise, so lack of motivation wasn't a trigger for me, but I've noticed now that even my motivation has improved. The biggest improvements I saw were in strength and endurance — I could essentially double the number of push-ups I could do.
Starting With Thyroid
You had a gradual start with different hormones. Mine began with thyroid, because a test showed I had a thyroid nodule. Everybody has thyroid nodules of various sizes, but I thought I'd try a little thyroid to see if I could help reduce it. When I started that replacement, I got more energy and actually slept better. Then things started to wake up and progress, so I went to advanced hormone replacement courses to see what else I was missing — and there's a lot more to it. Once I started replacing those, I found I had more fuel in the tank.
There's a metaphor about low testosterone: it's like driving on a nearly empty tank. The engine still runs, but it sputters and isn't as efficient.
Symptoms of Low Testosterone
Some symptoms of low testosterone in men include low energy, loss of drive and motivation, decreased libido, and weaker morning erections. Just as a woman's menstrual cycle is a vital sign that tells us how things are working, erections do the same thing for men — morning erections can be weaker with low testosterone, and replacing it helps.
One thing I like to encourage in the men in our practice is that we're able to reduce their visceral fat by improving testosterone. Testosterone does a multitude of things — brain, bone, cognition — but visceral fat is the metabolic part that makes us unhealthy, and while improvement isn't immediate, it does work over time.
The Statistics and the Metabolic Connection
Only about 40% of men over 45 are clinically diagnosed as low testosterone — and many more are "normal but not optimal." Optimal levels are well up into the upper hundreds when we're younger, then decline slowly and steadily. Some studies show only 5 to 10% of men are ever diagnosed or treated, so very few see any recovery.
Men with low testosterone have two to three times the rate of metabolic syndrome, which progresses into type 2 diabetes. Metabolic syndrome is increased waist circumference, elevated triglycerides, low HDL, elevated fasting glucose, and elevated blood pressure. The big improvements I see with testosterone replacement are muscle maintenance and synthesis (and those push-ups), glucose control, mood, energy, and libido.
Thyroid and DHEA
Thyroid is another substantial hormone. Low thyroid can give you that sluggish, fatigued feeling. Clinically, hypothyroidism is different from having symptoms of thyroid deficiency. TSH is typically followed to diagnose hypothyroidism, along with free T4, but when we look at thyroid deficiency we also look at free T3 (the active form) plus the person's symptoms — hair thinning, constipation, slow metabolism, high cholesterol, sluggishness. Both create similar symptoms, but a lot of people walk around with a thyroid deficiency related to those symptoms.
DHEA is the other hormone I was introduced to. It's a precursor from the adrenal glands — a precursor for testosterone — that also improves fat metabolism and boosts the immune system. I see improvements in muscle tissue synthesis and healing with it too. Like other hormones, DHEA starts to decline at age 30, a slow, steady decline for both men and women.
What We Test
For labs, we look at total and free testosterone. Some people only look at total, which is what we use for diagnosing hypogonadism, but free testosterone is the amount actually floating in your system not bound by sex hormone binding globulin — and that's what gives you symptom relief. We also look at sex hormone binding globulin, LH, and FSH (which we look at for women too, but which still indicate what's going on in men's hormone health), and DHEA (an adrenal lab).
We also draw thyroid panels — TSH, free T4, free T3, and thyroid antibodies — plus fasting insulin (mine was elevated back when I wasn't eating right), lipids (cholesterol, LDL, HDL), hemoglobin A1C, vitamin D (important for hormone and bone health), and inflammatory markers like C-reactive protein, homocysteine, and uric acid. It all helps us get the overall picture of how things are changing and what can be improved.
Long-Term Benefits
Some long-term benefits for me: reducing fat mass and increasing lean muscle. I wish I'd checked my body composition before starting, but I dropped several inches off my waist even though I wasn't overweight — it just feels better now, and I have a hard time finding pants that fit. I've also seen improvement in cognition — recalling names, remembering why I walked into a room. My blood sugar numbers, insulin, and A1C have changed too.
Interestingly, your inflammatory markers have never looked too far off because of your higher bilirubin. I have Gilbert syndrome, where an enzyme doesn't convert my bilirubin, so my total bilirubin runs a little higher — which is actually anti-inflammatory, a good thing.
With thyroid optimization, we see improved cholesterol, metabolic rate, and cardiovascular health. DHEA, being an adrenal hormone, relates to stress and helps promote resilience. And in optimized men and women, going through the advanced bioidentical hormone replacement courses, we're looking at an overall lower all-cause mortality of 30 to 50%. Sign me up. The question is: are you happy where you're at, or do you want to feel better, look better, and live a healthier life? I chose to get optimized.
Fears and Misconceptions
Some fears are still rampant but becoming more accepted. Testosterone replacement therapy does not cause prostate cancer — that's a myth. There can be a reduction in testicular size, but it's usually temporary and not a big deal. Very high testosterone can make some individuals more aggressive, but with optimized levels we actually see a less irritable, more balanced, more manageable mood — you feel better, so you're in a better mood. It's watched for and managed, and as people get healthier and reduce their environmental toxin load, you may have to adjust their levels.
Another common thought is, "Do I have to be on this for life?" Well, do you want to be metabolically unhealthy for life? Do you want to take statins and blood pressure medicine, or do something to reduce your all-cause mortality and improve your quality of life? You don't have to be on it forever — you can decide to stop when you want.
Treatment Options
For myself, I chose creams and pills. There are also injections and pellets, which have their place, but injections and pellets can produce higher, supraphysiologic levels for a short period, whereas creams give a more balanced, physiologic flow of testosterone systemically. Regarding DHT, some men who apply cream will see elevations, and there are studies supporting either side — you can find a study to back up almost anything and just have to draw it out of the data. Some men worry about DHT causing prostate hypertrophy or thinning hair, but at this stage I haven't seen that in myself or the patients we treat.
Thyroid replacement, similar to women, includes both T3 and T4 — combination therapy, not just synthetic T4 — in a good ratio to be successful. And DHEA is an oral supplement, once a day, very easy to take.
Final Reflections
What have I found on hormone replacement therapy? A better and healthier way of life — I've seen improvements in my body composition and labs. What would I tell my pre-hormone-replacement self, who was healthy and didn't have a lot of complaints? It boils down to how you want to live. When you get older, do you want to worry about developing chronic diseases stemming from hormone imbalance, or do you want to improve your quality of health, strength, motivation, and endurance? It's nothing to be scared of.
The other thing is I didn't realize how much improvement there was — I didn't know what I didn't know. Going from being able to rip off only so many push-ups to it being almost unlimited is a real difference. I'm active not just in sports but around the house with projects, and we travel to running, hiking, and biking events. I don't have any trouble performing those anymore, and I just enjoy being able to do what I enjoy.
Thank you for sharing your story. If anyone has gained some knowledge or come up with questions, feel free to reach out — we're here to have the conversation. And ladies, if you know your man would enjoy a male perspective on hormone replacement therapy, let him listen to the podcast. Have a healthy day.