HRT article

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Nowadays, when a person reaches 40 or 50, they may have only lived half their lives, unlike their ancestors, who even 100 years ago, were considered old. We expect to sit on the banks of the pond and see the reflection of a smooth-skinned, svelte young adult smiling back -- the person that exists within our psyche. But the mirror, unkind horror that it is, often reflects a different story.

Those who have taken good care to maintain their health and appearance don't look elderly, but both sexes begin to undergo a decline in hormone levels. Although men never come to the end of their reproductive lives naturally as do women, they still experience a great many changes.

Most are quite happy to be rid of baby diapers and other child-rearing chores. That's the good part. The bad part is that the hormones that control our reproductive systems also control a lot of other things that we'd love to hang on to, like being able to eat and drink whatever we want without paying the piper. Unfortunately, there is no way to turn back the clock -- you only go around once and you can either grow old or die young.

There is medical help available nowadays, but it is often a double-edge sword. For some reason giving estrogen to women was, and still is, acceptable, maybe because a bunch of male doctors were/are being driven nuts by their menopausal wives! Although it can relieve a lot of unpleasant symptoms, synthetic estrogen and progesterone replacement has been linked to breast and cervical cancer.

The opposite opinion was held when it came to giving men the equivalent, i.e. testosterone, because everyone knew they would morph into King Kong, chasing innocent women through the streets. Although attitudes have now changed, there are still many doctors who refuse to prescribe it, or prescribe it at such low levels that it's a waste of the patient's time and money. Testosterone definitely helps a man's libido, but does many other things as well, including promoting feelings of well being. The downside is that given in too high a dosage, it can promote oily skin and blemishes and convert to estradiol (a form of estrogen).

Men and women naturally produce both testosterone and estrogen, albeit in different amounts. Small amounts of additional testosterone given to middle aged women can increase sagging libidos. Men shouldn't let their estradiol levels drop below a certain percentage because they can suffer bone loss and other problems, so the "macho" fear of some physique community proponents about men's estrogen levels is totally incorrect and dangerous to a man's health.

Many people live their entire lives never requiring any sort of hormone replacement therapy whatsoever. Those who feel they might be candidates for HRT need to understand that they must find a happy medium for their individual bodies. Before you begin, even if your doctor thinks you should, do yourself a favor and become self-educated first. For those whose doctors won't hear of such a thing, you need to know the facts so you can talk about the subject with some intelligence and find out how to locate a doctor who understands the problem.

Excellent discussions on this topic are outlined in articles (1) by Karlis Ullis, M.D. (2) and his associate, Joshua Shackman, M.A. (3). These articles and Dr. Ullis' and Mr. Shackman's books are written for the lay public. A quite lengthy and somewhat scientific dissertation can be found on the Life Extension Foundation Website (4, 5). Readers are reminded that LEF sells supplements, thus the latter part of their discussion promotes their products.

This is understandable because often the hardest part for both sexes is locating a doctor who really understands hormone replacement therapy. LEF provides a list of physicians who specialize in this field (6). You may have to travel outside your locality to visit one, but once your protocol is established, you shouldn't need to visit that person more than a couple of times a year. Your chosen physician should insist upon having, and be able to interpret, hormone blood levels so that your treatment is on an individual basis according to your needs.

Because HRT is more acceptable now than previously, many insurance companies will pay for some, or all, of both doctors' visits and the hormones themselves. However, before you assume that yours will, check with them to be certain.

A Short Overview

It is recommended that you read the referenced articles for a more in-depth understanding of the changes your body undergoes and what steps you may be able to take to retain your youthful vigor (this is not just about looking good). The following is not medical advice. It is for informational purposes only.

Karlis Ullis, M.D. states in his Muscle Monthly articles (1) that his approach is really "hormone balancing, [i.e.] keeping [a person's] sex hormones (testosterone, estrogen and progesterone) at the same levels that they were [when that person] was in their mid-twenties."

As men age, their bodies naturally manufacture less testosterone or convert it to estradiol. This throws off the youthful ratio, causing many side effects that may include depression, fatigue, a female-type fat distribution pattern, muscle wasting, diabetes and prostate enlargement. Many of these conditions can be reversed by proper exercise and diet, but this strategy only goes so far for someone who truly needs medical intervention.

After performing a thorough medical exam and comprehensive hormone panel (blood test), Dr. Ullis determines the best approach for each patient. He bases his conclusions on the following:

1. A deficiency or imbalance that has been shown by lab tests results.
No sign of cancers that might be exacerbated by hormones.
Subjective responses to questions, i.e. whether the man has been depressed, is suffering from low-self esteem, lack of sex drive, has had problems gaining muscle even when he's been working his butt off in the gym, etc.
Because male "andropause" is a slow process, Dr. Ullis may not start a patient on testosterone immediately because doing so could "potentially shut down his sex hormone production completely, especially if higher than normal testosterone levels are maintained."

Many readers are very familiar with what occurs in men who take high doses of anabolic steroids, of which testosterone is really the basis. Often their libidos sag and if they stay on too long, they end up in a doctor's office in an attempt to jump start their natural hormone production. In between the time they stop the AAS and the time their bodies decide to function properly, they experience a host of problems that can include sore joints, gynomastica (painful fatty deposits beneath the nipple area that often require surgical removal) and symptoms of withdrawal and depression.

This is also true when someone who uses supplemental testosterone for anti-aging purposes decides to stop. According to Dr. Ullis, it can take six to nine months for normal production to resume after discontinuing HRT and many "may find that they need to stay on it the rest of their lives." If you have to stop for some reason, what then?

Thus no reputable medical doctor will prescribe more testosterone than what a patient needs to maintain normal levels for good health. If you want to pack on muscle legally, you're simply going to have to do it the old fashioned way, although raising testosterone levels to what they were in men who had normal mid-20's levels will help a great deal in the endeavor.

If you are tested when you are fairly young and keep the results in your medical file, you will easily be able to track the variations in later years. If your doctor refuses to order these tests, you can order them yourself through the Life Extension Foundation (7).

Dr. Ullis employs several options for balancing a man's hormone levels. The first is what's known as an "aromatase inhibitor." When testosterone "aromatizes," it converts to estrogen, one of Mother Nature's chemical magic tricks. This also happens in women and for those who have breast cancer, which is exacerbated by this situation; several pharmaceuticals have been developed as protocols for this condition.

The best choice currently is a drug called anastrozole, which is marketed under the brand name, "Arimidex." What this does is keep a man from converting his endogenous (naturally produced) testosterone to estradiol. Often this is all that's required because "Arimidex may actually increase [the body's] release of lutenizing hormone from the pituitary gland. Lutenizing hormone is the main hormone responsible for signaling the testes to produce more testosterone."

So not only does an anti-aromatase not shut down a man's normal testosterone production, but the dose can be structured to his individual requirements. This is an expensive prescription medication, although it can be purchased through mail-order pharmacies in Canada at about half the cost of what it sells for in the U.S. (8). Often, however, a man does not need to take an entire tablet each day, but can take a half or quarter tab, or structure the dose in some other manner.

From time to time, Dr. Ullis has also encouraged certain patients to try the over-the-counter prohormones, androstenedione and 4-androstenediol because they do boost testosterone, albeit on a temporary basis. The article from which this information has been extrapolated was written just as ErgoPharm's® product, 1-AD™ was hitting the market. Although there is no evidence that this will work, Dr. Ullis theorizes that "it might make a useful supplement for men with low testosterone levels and high estrogen levels . . . as a good alternative to [prescription] testosterone in that it may have many of the same effects on improving mood, energy and libido . . . without conversion to estrogen."

Although Dolfzine® in no way endorses any supplement,1-AD™ was designed by chemist Pat Arnold, who figured out a way to put a prohormone into an oral product in a structure that bypasses the liver, which is the biggest problem with other orals. Sprays and sublinguals were designed in this manner as well, but many people do not like dousing themselves with an alcohol-based spray twice a day or sucking on a rather bad tasting tablet for 30 minutes.

Unless your doctor recommends you use prohormones as a way to boost your natural testosterone levels, it is recommended that before you try them you do adequate research on the subject to make sure they will not cause unwanted side effects or other problems, such as disqualification from certain sporting competitions. Younger men absolutely do not need them, no matter what the supplement manufacturers say, and for women of child-bearing age they are even more of a "no-no." (Please keep in mind that the purpose of this article is to present information, not to encourage you to turn yourself into a living lab experiment. These products are being sold. It is wise to understand what they are.)

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For men who get poor results from the above methods, the next alternative is prescription testosterone. There are three methods of delivery -- injectible, patches and gels.

The most often used injectible was testosterone cypionate which was inexpensive both to manufacture and purchase. Unfortunately in the early summer of 2002, Upjohn stopped manufacturing this product. The best guess as to why this occurred is that the government may have simply placed too much red tape record keeping on Upjohn to make something with such a low profit margin worthwhile. Though this is an unproven supposition, it is a generally held belief in medical circles.

That leaves testosterone enthanate manufactured by Bristol-Myers Squibb. This is a much more expensive product although it is slightly more advantageous because it does not cause as much water retention, one of the side effects of testosterone supplementation.

The problem with injectibles is that men either have to show up at their doctor's offices every two weeks (the usual protocol) when weekly injections are better, or inject themselves. It's not that people can't learn to give themselves shots; diabetics do it daily. But this is intramuscular in an oil based suspension, so you need to know what you're doing. In addition testosterone levels are highest after the shot and then decline as time passes. Although this does suffice, it is not the way that the body naturally releases this hormone.

Most men opt for the convenience of patches or gels. Patches are often very problematic, producing skin rashes from the adhesive, falling off due to perspiration or showering, and ugly to look at. They have been pretty much bypassed in favor of AndroGelâ„¢.

AndroGelâ„¢ is a much better product as far as delivery because when put on twice a day, it mimics the normal rise and fall of blood levels of natural testosterone. It's very easy to apply and leaves no telltale residue. The downside is that a man should definitely not rub it on, then a few minutes later hug a child or a pregnant woman.

The same holds true for the prohormone sprays. Dr. Ullis cautions that these products "in the suggested doses . . . may boost your testosterone levels much higher than AndroGelâ„¢. The recommended dose of AndroGelâ„¢ is only 50 to 150 mgs/day, while the prohormone sprays list the upper range dose as high as 800 mgs/day." If you're using these sprays for HRT, then you would need to adjust the dose accordingly.

Side Effects of Testosterone

Like all other medications, testosterone can cause a lot of problems if not used properly. The athletic community often has a "more is better" mentality, but shooting up more testosterone is not like eating a couple of extra helpings of broccoli.

In pubescent males, testosterone levels are sky high. Although they often cause oily skin and acne, these young guys don't have problems with prostate enlargement and hair loss. Of course this might be simply because it hasn't been coursing through their systems long enough. Maybe it's the same reason these kids can also eat an extra large pizza and not get indigestion. Eventually one's system finally says, "Enough already!"

However, what seems to be happening is that as men age and their testosterone levels fall, they start to experience what was once thought to be the bane of high testosterone levels, i.e. heart disease, prostate enlargement and male pattern baldness. It is now believed by many doctors that estrogen is a greater culprit in this story, at least in men with testosterone deficiencies.

Even so, it pays to proceed with caution. Dr. Ullis insists his male patients be regularly tested for prostate problems as well as placing them on various prostate-protecting supplements that include "saw palmetto, quercetin, and lycopene" in order to help "prevent prostate enlargement and inflammation," and possibly prevent cancer as well.

The bottom line for men is that HRT can "have powerful anti-aging effects if the proper treatments are used." Many can actually "find a new lease on life and sexuality" after their hormones are restored to youthful levels. "The key . . . is finding the right treatment option."

What About the Girls?

Many women are taking supplemental estrogen. Often this is handed out whether it's needed or not. During a routine office visit some years ago, my doctor flipped through my chart and stated, "Let's see, you're 52. You should be taking estrogen." My question was "Why? I'm not having any problems." I got the usual lecture about osteoporosis, never mind that I was working out like a madwoman four days a week in the gym. My response was that if he wished to prescribe a hormone, I'd prefer to have testosterone. He laughed although he did agree that for my goals, it would be the better choice.

Because I was so entrenched in the physique community, which is often several years ahead of the mainstream, I had become aware that Premarinâ„¢ and Proveraâ„¢, synthetic estrogen and progesterone, respectively were possible causes of breast and cervical cancers. Several women I knew who were undergoing treatment for these conditions had taken these medications.

The present thinking in the up-to-date medical community has changed toward the use Premarinâ„¢ or Proveraâ„¢ and doctors have become more cautious or often seek other alternatives.

The problems with these synthetic estrogens are that they are manufactured from the urine of pregnant horses. Even though human estrogen is close, it's not quite the same. Natural human estrogen as we think of it, is not one compound, but three, i.e. estrone, estradiol and estriol. Horses have a different ratio than humans, not to mention some hormones that humans don't even have in the first place. It is this difference, used over a period of time, that is thought to be the a possible cause of cancer.

There are women who have taken Premarinâ„¢ and Proveraâ„¢ for years, like 20 or 30! - and are doing fine. Currently most doctors will not give these drugs to women who have a family history of reproductive cancers.

Dr. Ullis has a contrary opinion to much of the mainstream. "Believe it or not, there are actually more women who need testosterone replacement therapy than men." The reason for this is that even in peri-menopause (the period before actual menopause) women "stop producing testosterone almost completely or have very low levels of free testosterone and precursors such as DHEA and androstenedione."

When women's testosterone levels get low, they suffer from the same complaints as men, thus it should be considered "as a front line treatment." Dr. Ullis states that small amounts (usually a gel needs to be made specifically for each woman by a compounding pharmacy) can turn women's lives around. They perk up, lose fat, have an interest in sex and even make rather dramatic improvements in their exercise programs.

Like men, women shouldn't just go willy-nilly slapping on dabs of their man's AndroGelâ„¢! They also need a blood panel and cancer screening tests.

Dr. Ullis has also recommended prohormones for some female patients, albeit in very small doses. However, with these over-the-counter prohormones, unlike a pharmaceutical grade cream, there is no controlled regulation as to quality, ingredients and dosage in the supplement industry. (They can also cause very unsightly skin problems.)

After the recent problems with athletes testing positive because 19-norandrostenedione was being surreptitiously slipped into protein powder without anything being put on the label and without the purchaser being any the wiser, one can also wonder what else is in the unlabeled prohormone bottle.

So What About Big E?

Dr. Ullis does not prescribe Premarinâ„¢ for two reasons. The first is that not every woman needs estrogen replacement, and secondly he is of the mind that it definitely can increase the risk of breast cancer. It can also lead to unnecessary weight gain in a population that already has enough problems in this regard.

If women are experiencing uncomfortable symptoms such as hot flashes, natural plant phytoestrogens may help in this regard "and may actually lower the risk of breast cancer and do not lead to weight gain." This is particularly fortuitious because many women have problems that interfere with their lives at a time when they can least afford it. Many are at the epicenter of a circle that includes an employer, older children and elderly parents. A middle aged woman is trying to juggle these while still trying to find time for her husband or significant other and herself. She needs all the energy she can get!

So what if you're one of these women whose body just does a number on you and you wake up every night drenched to the skin, cry at the drop of a hat, get angry for no good reason, have no interest in sex, etc.? If phytoestrogens don't solve your problems, Dr. Ullis would probably prescribe a natural "bio-identical estrogen" cream or gel, favoring "estradiol over estrone and estriol since these latter two forms of estrogen are possibly transformed into more toxic metabolites." He always encourages his patients to discontinue Premarinâ„¢. In fact he feels that some problems women encounter, i.e. the inability to lose fat, may be "due to the excess estrogen" they have been ingesting.

Hormone No. 3 - Progesterone

We hear about this constantly, but what is it? In young women, progesterone is the primary hormone that prepares the lining of the uterus to receive and accept a fertilized ovum. Is this something that's necessary for a woman past childbearing age? Nature obviously doesn't think so, but Nature shuts down other hormones as well.

Proveraâ„¢, which is a synthetic compound that doesn't quite match the natural human hormone, is "somewhat androgenic . . . women can become irritable and agitated from using it [as well as] experience other side effects such as acne." Natural progesterone, on the other hand, "can have a calming, relaxing effect on women."

The combination of synthetic estrogen and progesterone is usually the weight gain culprit because while estrogen encourages fat storage, progesterone increases appetite. Natural compounds have the opposite effect, or at least a neutral effect.

If you, as an over-fat woman wish to lose weight, Dr. Ullis recommends you forget progesterone, and especially Proveraâ„¢. On the other hand, for a woman who might be at risk for endometrial cancer, he will often recommend very small doses of a natural gel. Dr. Ullis' final statement is that he believes the combination of Premarinâ„¢ and Proveraâ„¢ to be "a travesty against women and may be one of the major factors behind the obesity epidemic in America." Strong words, but worth heeding.

Human Growth Hormone (hGH)

If you've picked up a muscle glossy at any time over the past few years, you're bound to come across some article discussing the fabulous success of those who have used hGH. The supplement industry has rushed out a bunch of products they claim will boost your natural production. These products are scams and a complete waste of money.

Prescription Growth Hormone is ghastly expensive and must be injected, like insulin, just under the skin and at the proper time of the day to coincide with the body's release. Most people find this extremely inconvenient not to mention that unless someone has been medically tested and shown to be deficient, like the supplements, it's a total waste of time and money. Dr. Ullis reports that he does have patients who have been screened and have come up short. If that's the case then he will prescribe it for them, but only if they do not respond to other therapies first.