15. Men's health

Question 1

What is testosterone - androgens?

Answer 1

Testosterone = a steroid sex hormone under hypothalamic and pituitary gland control.

Question 2

where is testosterone produced?

Answer 2

• Produced: In men >95% from the testes by Leydig cells, with the remainder mostly from the adrenals.

Question 3

what is the function of testosterone ?

Answer 3

• Functions: Male sexual characteristics — facial hair, deepening of voice, development of penis and testes, libido and sperm production. Skeletal muscle growth and increases bone density.

Question 4

how does testosterone circulate?

Answer 4

• Circulation: ~60% is weakly bound to albumin and ~40% tightly bound to SHBG. ‘Free testosterone’ accounts for ~1-2%. ‘Bioavailable testosterone’ = free + albumin-bound testosterone.

Question 5

what is low testosterone?

Answer 5

Low testosterone = the most common type of male sex hormone imbalance (often combined with high oestrogen).

Question 6

signs and symptoms of low testosterone?

Answer 6

• Signs / symptoms: Central weight gain, low energy, low libido, erectile dysfunction, infertility / low sperm count / motility, osteoporosis, hair loss, fatigue, loss of muscle bulk and strength, mood changes.

Question 7

causes and risk factors of low testosterone? x9

Answer 7

1* – Ageing — declines with age after 40 years by ~1% each year.
Associated with symptoms referred to as the ‘andropause’.
2* – Chronic stress — cortisol and epinephrine have inhibitory effects on testosterone release.
3* Elevated SHBG ― binding too much testosterone, e.g., medications (metformin, tamoxifen); liver disease and dysfunction ― impaired SHBG detoxification; anorexic states and overtraining.
4* Thyroid dysfunction ― likely through its effects on SHBG.
5* Zinc deficiency ― it supports testosterone production.
6* Increased aromatase activity (e.g., obesity, insulin resistance, excess alcohol; inflammation and ↑ PGE2).
7* Environmental toxins ― e.g., BPA can bind to androgen receptors.
8* Sleep deprivation ― testosterone is made mostly during sleep.
9* Medications ― e.g., opioids (inhibit GnRH).

Low testosterone is also associated with IR and ↑CVD risk

Question 8

natural approach to low testosterone? x6

Answer 8

1* Address the cause, e.g., stress support (see stress lecture), weight loss, thyroid support (see endocrine lecture) etc.
2* CNM Naturopathic Diet with low GI foods, healthy dietary fats (pregnenolone synthesis), zinc-rich foods (testosterone synthesis).
3* Exercise ― resistance training (e.g., weights) and HIIT ↑ testosterone.
4* Sleep hygiene; avoid xenoestrogens (see women’s health).
5* Support liver detox and balance gut microbiome (oestrobolome) ― to ↓ SHBG and oestrogens (see Detoxification + Women’s Health).
6* Mitochondrial support (e.g., B vitamins, CoQ10, alpha-lipoic acid, Se, glutathione, etc.,) ― pregnenolone is formed in mitochondria.

Question 9

Nutrients for low testosterone x5

Answer 9

1. Zinc 15‒30 mg / day * Supports testosterone production, and promotes spermatogenesis.
2. Vitamin D Optimise levels * Increases Leydig cell testosterone production and supports a health testosterone / oestradiol ratio.
3. Magnesium 200‒400 mg / day * In combination with zinc and B6 shown to improve testosterone levels in athletes.
4. B complex 50‒150 mg / day * Mitochondrial support (for pregnenolone synthesis). Methylation support (↓ homocysteine and CVD risk).
5. D-chiro-inositol 600 mcg x 2 / day * Modulates aromatase — ↓ conversion to oestrogens. Also supports cell insulin sensitivity.

Question 10

Herbs for low testosterone x4

Answer 10

Ashwagandha (Withania somnifera) 2‒5 g powder/ day * Increases testosterone (and DHEA) by stimulating GnRH production. Might also inhibit aromatase activity.

Mucuna pruriens Up to 100 mg / day * ↑ Leydig cell production of testosterone, likely through ↑ dopamine↑ GnRHFSH + LH.

Tribulus terrestris 500–650 mg / day * ↑ free testosterone by ↑ LH release. It also ↑ libido, NO synthesis and sperm motility.

Shatavari (Asparagus racemosus) Up to 3 g powder / day * Its steroidal glycosides exert
testosterone-like effects. Considered an aphrodisiac.

Nettle root, fenugreek and maca root also support testosterone levels

Question 11

What is DHT?

Answer 11

Dihydrotestosterone (DHT):
* Produced: From testosterone by 5a-reductase.
* Activity: The more potent androgen (approx. 2–5 x stronger than testosterone). It binds more strongly to androgen receptors and does not aromatise into oestrogen

Question 12

What are the consequences of increased DHT?

Answer 12

Increased DHT levels: Associated with acne, male pattern baldness, mood (anger), prostate disorders.

Question 13

Causes for increased 5 alpha reductase activity? where is it located?

Answer 13

Causes of ↑ 5a-reductase activity: Inflammation (i.e., poor diet gut health etc.,) ↑ insulin, obesity, low zinc status, pesticides, steroid 5-alpha reductase type 2 (SRD5A2) SNP.

5a-reductase is located in the gonads, skin, hair and NS

Question 14

How to lower DHT via a reduction of 5 alpha reductase?

Answer 14

Address inflammation (see immune lecture), stabilise blood glucose levels and support insulin sensitivity (see endocrine lecture), reduce adiposity, eat organic.

Question 15

Herbs/nutrients to reduce 5 alpha reductase x3

Answer 15

1. Zinc 15–30 mg / day * ↓ 5α-reductase activity, stabilising DHT levels.
2. Saw palmetto (Serenoa serrulata)
   500–1000 mg (berry) * Its high levels of beta-sitosterol inhibit 5α-reductase and DHT binding to androgen receptors.
3. Stinging nettles (Urtica dioica)
   300–600 mg (root) * Inhibits 5α-reductase and aromatase (reducing DHT and oestrogen); binds to SHBG, increases testosterone.

Question 16

what is erectile dysfunction? what is occasional ED?

Answer 16

Erectile dysfunction (ED) or impotence = the inability to achieve or maintain an erection firm enough to have sexual intercourse.

Occasional ED’ is common ― it is often experienced during times of stress, anxiety or relationship problems. ‘Frequent ED’ can be a sign of an underlying health problem.

Question 17

Causes and RF of ED? x7

Answer 17

Causes / risk factors:
1* Low testosterone ― see earlier (e.g., long-term alcohol, obesity).
2* Stress, anxiety ― increases sympathetic NS activity; noradrenaline is the primary ‘anti-erectile’ neurotransmitter. Consider relationship difficulties.
3* Dietary — low whole-grain foods, legumes,
vegetables, fruits, and high red meats, refined sugars and dairy products are linked to ED. Likely due to the higher antioxidants and citrulline (↑ NO).
4* Diabetes mellitus — associated with ↑ AGEs, ↑ free radicals, impaired nitric oxide synthesis and neuropathic damage.
5* Medication induced — e.g., β-blockers, anti-depressants, opiates.
6* CVD — atherosclerosis results in arterial insufficiency. See CV health for specific risk factors, but consider hypertension, IR, smoking, etc. Low NO synthesis (e.g., low arginine, vitamin D etc.) Causes / risk factors (cont.):
7* Neurogenic — deficit in nerve signalling to the corpora cavernosa. E.g., lumbar disc herniation, MS, Parkinson’s.

Question 18

Natural approach to ED x4

Answer 18

1* Address the cause, e.g., Diabetes mellitus.
2* CNM Naturopathic Diet with the focus on phytonutrient-rich plant foods, alcohol elimination and healthy weight management.
3* Moderate exercise including both cardio and calming exercise (yoga, tai chi) to reduce stress and aid circulation.
4* In cases of low testosterone, address the underlying cause and see earlier recommendations e.g., Tribulus terrestris.

Question 19

natural approach to ED - emotional cause

Answer 19

• Apply therapeutics as per the Stress lecture (magnesium, vitamin C, B vitamins, L-theanine; solving stress / problems) and Nervous System lecture (B6, passionflower etc.)
• Adaptogens — ashwagandha (see earlier), Panax ginseng (1000 mg x 3 daily), Siberian ginseng (100–300 mg x 2 daily). The ginsenosides in ginseng promote NO release.
• Bach flowers — mimulus (fear around sexual contact, fear of not being able to perform), larch (loss of confidence in sexual ability), olive (where stress and / or fatigue impact libido), star of Bethlehem (previous traumatic event that contributes to ED).
  Bach flowers: 4 drops 4x daily

Question 20

nutrients/ herbs for ED

Answer 20

1* Support CV health (see CV lecture). To support penile blood flow include circulatory stimulants, e.g., ginger, rosemary, cayenne.
2* Beetroot juice / powder (5–10 g) to increase NO production.

3/Arginine 1500–5000 mg / day * For NO production => vasodilation. Low L-arginine levels have been recorded in men with severe ED.
4/ Vitamin D Optimise levels * Regulates NO synthesis by mediating eNOS; vascular protective — for endothelial health.
5/ Ginkgo biloba 60‒120 mg x 2 / day * Improves blood circulation by antagonising ‘platelet activating factor’ — causing vasodilation.

Question 21

What is benign prostate hyperplasia ?

Answer 21

Benign Prostatic Hyperplasia (BPH) = enlargement of the prostate without the presence of malignancy.
* Affects approximately 40% of men over the age of 50 and 90% over the age of 90.

Question 22

signs and symptoms of BPH?

Answer 22

• Signs / symptoms: Urinary frequency, urgency, hesitancy, nocturia, incomplete evacuation, terminal dribbling.

Question 23

what is the PSA blood test for BPH?

Answer 23

PSA blood test: A raised PSA indicates possible prostate enlargement or inflammation. It is normally used as a screen for prostate cancer. Levels >4.0 ng / ml “require investigating”.

Question 24

Aetiology of BPH

Answer 24

• Whilst DHT is required for normal prostate function, higher levels can cause pathologic prostate growth in adult men.
• See earlier causes of raised DHT — e.g., obesity, IR, inflammation, excess alcohol, low zinc status etc.
• High stress (↑ SNS activity)↑ norepinephrine stimulation of α-adrenoceptors on prostate smooth muscle cellssmooth muscle hyperplasia.
• A higher ratio of oestrogens to testosterone. Oestrogens ↑ prostate growth. Declining testosterone >40 years of age can heighten the affect of oestrogens and xenoestrogens on prostate tissue.

Question 25

Natural approach to BPH?

Answer 25

• CNM Naturopathic Diet with a focus on zinc-rich foods (5α-reductase inhibitor) and organic foods (avoiding 5α-reductase promoting pesticides).
• See earlier section on lowering DHT (e.g., zinc, saw palmetto, nettle). Note: Zinc has been found to correct mitochondrial apoptosis, thus affecting growth / differentiation of prostate tissue.
• Optimise body weight; address stress (see Stress lecture) to reduce SNS activity; Vagal stimulation (see Nervous System lecture).
• Remove alcohol, caffeine, artificial sweeteners and fizzy drinks which can irritate the bladder and make urinary symptoms worse.
• Include a rainbow of plant foods. Many polyphenols inhibit 5α-reductase activity, reduce inflammation and oxidative stress, e.g.: ‒ Lycopene — inhibits 5α-reductase and interleukin-6 signalling.
• Reduce excess oestrogens (see Women’s Health) — ↓ xenoestrogens (e.g., BPA), aromatase inhibitors (e.g., flavonoids, white button mushroom, inositol), phase I and II detox support (e.g., I3C, methylation), bowel clearance (e.g., fibre, 5R / probiotics).
• Beta-sitosterol (60‒130 mg / day) improves urinary symptoms and flow in BPH (found in pumpkin seeds, saw palmetto, nettle root). It inhibits 5α-reductase and aromatase.
• Physical activity — there is an inverse association between this and BPH. It has been shown to improve nocturia in BPH.

Question 26

nutrients / herbs for BPH x4

Answer 26

1. Selenium 200–600 mcg * An essential component in the antioxidant glutathione peroxidase. ↓ hyperplasia, PSA levels and irregularities in the prostate nuclei.
2. Reishi 3–9 g / day * Shown to inhibit 5α-reductase and reduce PSA levels.
3. Vitamin D Optimise levels * Shown to decrease prostate cell proliferation (especially when induced by DHT, Il-8 and IGF-1). Anti-inflammatory — inhibits COX-2 and PGE2.
4. Berberine 50–250 mg / day * ↓ prostatic hyperplasia in BPH by inhibiting 5α-reductase, ‘extracellular signal-regulated kinase’ (ERK) and NF-κB.

Question 27

Prostate cancer signs and symptoms?

Answer 27

Prostate cancer = the most common cancer in men 50+ years.

Signs / symptoms: Same as BPH with addition of haematuria, blood in the ejaculate, pain on ejaculation, back pain (possible spinal metastases).

Question 28

Prostate cancer risk factors?

Answer 28

1* Dietary — processed meats, high refined sugar, low fibre, caffeine, high saturated and trans fats increase the risk of prostate hormonal dysregulation, oxidative stress and inflammation as well as altering lipid metabolism and growth signalling. Dairy products (↑ IGF-1).
2* Abdominal obesity (see Obesity Lecture for causes) — ↑ insulin resistance, chronic inflammation and dysregulated sex hormones.
3* Poor methylation (e.g., due to lack of key nutrients, COMT SNP) — ↑ 4-OH-E (CYP1B1) activity and quinone formation which cause oxidative damage to DNA. Also consider a low antioxidant status.
4* Increased 5α-reductase activity  ↑ DHT (see earlier).
5* GIT ― intestinal dysbiosis can ↑ β-glucuronidase  raised circulating oestrogens.  cell proliferation. An impaired intestinal barrier can result in chronic low-grade inflammation.
6* Nutrient deficiencies / insufficiencies; e.g., Zn, Se, vit. D (see later).
7* SNPs e.g., CYP3A4 polymorphism (CYP3A4 enzyme is associated with oxidative deactivation of testosterone).

Question 29

Natural approach to prostate cancer

Answer 29

• CNM Naturopathic Diet (e.g., remove dairy) with a focus on zinc and selenium-rich foods. A Mediterranean style diet has been shown to prolong prostate cancer survival rates when coupled with exercise.
• Quercetin, resveratrol, EGCG and curcumin increase both intestinal and prostate zinc absorption rates.
• Lycopene (2 tbsp tomato purée daily) — induces apoptosis and blocks the intercellular gap junction communications responsible for the invasion and metastasis of prostate cancer.
• Support as needed (see respective lectures): Methylation, detox / elimination pathways, weight, intestinal microbiome and barrier.

Question 30

herbs/nutrients for prostate cancer x5

Answer 30

1/ Zinc 15–30 mg / day * Anti-carcinogenic ― stabilises DNA and RNA; inhibits prostate cancer cell line growth and invasion. Inhibits NF-κB. ↓ DHT.

2. Selenium 200–600 mcg * Increases glutathione peroxidase; low levels are linked to carcinogenesis (and prostate cancer).
3. Vitamin D Optimise levels * Antiproliferative activity. It can cause apoptosis, inhibit tumor cell invasiveness and suppress tumour-induced angiogenesis.
4. Reishi 3–9 g / day * Its triterpenes suppress the migration and invasion of prostate cancer cells and induce apoptosis by inhibiting
   matrix metalloproteinase (MMP) expression.
5. Shiitake 1.5–10 g / day * The beta-glucan lentinan has anti-proliferative and anti-angiogenic properties.

Also white button mushrooms (a handful 2–3 times per week) inhibits androgen receptor activity.

Question 31

What is prostatis?

Answer 31

Prostatitis = inflammation of the prostate with or without infection.

Question 32

Prostatis signs and symptoms?

Answer 32

• Signs / symptoms: Similar to BPH with the addition of frequent UTIs, dysuria, blood in the urine or semen, discharge from the urethra, pain on ejaculation; pain around male genitalia, anus, lower abdomen and lower back; fever and malaise.

Question 33

Prostatis aetiology?

Answer 33

• Aetiology: Chronic low-grade inflammation and low immune function (see Immune lecture). Links with low testosterone (see earlier). Genitourinary dysbiosis (proinflammatory bacteria such as E.coli, Streptococcus anginosus and Propionibacterium acnes are associated with infective prostatitis), as well as STDs (e.g., chlamydia)

Question 34

Prostatis natural approach

Answer 34

Natural approach: Address the cause!
* CNM Naturopathic Diet with a focus on reducing inflammation and immune support in infective cases (see Immune lecture). – EFAs, turmeric, ginger and vitamin C are PGE2
inhibitors and reduce inflammation in prostatitis.

Question 35

Prostatis nutrients/herbs x3

Answer 35

• Zinc, selenium, lycopene, saw palmetto and stinging nettle for prostate support (see earlier).
• Quercetin (500–1000 mg x 2 daily) — shown to reduce prostatic inflammation. Inhibits LOX, COX and NF-κB.
• Probiotics and prebiotics to increase microbial diversity and anti-inflammatory Prevotella which are often low in the gut microbiota of those with prostatitis.