Have you ever wondered why it is that plenty of help is available to women in the form of hormone replacement therapy (HRT) to help with the symptoms of the menopause in particular, and ageing in general, and yet nothing is available at all for men?

The simple answer, actually, is that help is available for men. It's just that it is not widely known about and few doctors provide it. This may seem like a major failing by the medical profession, but there are some good reasons for this poor availability. Firstly, while women go through quite a cataclysmic and often sudden collapse of their sexual hormone levels – the central cause of all the symptoms of the menopause – men go through a much gentler and hugely variable decline. This decline is sometimes called the andropause –namely the male menopause – but in most men this event is so gradual and drawn out that many doctors strongly dispute the very existence of the andropause. 

Whatever you want to call it, or not call it, men certainly do experience a decline in their sexual hormone levels, starting from their mid or late forties, and picking up speed in their late fifties and early sixties. The result is a decline in physical strength, stamina, energy levels, libido, self-confidence and mental acuity, to name just the most obvious. This is also often associated with an increase in weight. In short, they start to feel much less of a man than they used to be.

Why not provide male BHRT?

The problem for anyone thinking of treating this decline is that in men it is hugely variable. This necessitates a highly personalised treatment programme that can be enormously time-consuming. This makes it difficult for an organisation like the NHS to manage, geared as it is to attempting to provide the maximum good to the maximum number of people and at a low cost. 

HRT programmes are more feasible for women, as even the huge variation among women is relatively small compared to that seen in men, making it possible (at least in theory) to provide standardised hormone treatment doses and treatment programmes. The NHS, not surprisingly, simply cannot cope with the huge input required to manage the individual treatment programmes that would be needed for men.

The second problem that has held back development of HRT programmes for men is that incorrect hormone dosing – especially providing too high a dose of testosterone – can have serious effects on the prostate gland, which if not corrected could potentially result in prostate cancer.

So, HRT in men is problematic due to the huge variability from one man to another, plus the risk of damage to the prostate. That said, HRT treatment in men is perfectly possible, provided a careful and highly personalised approach is taken by both the doctor and the 'patient'. Furthermore, the results of such a careful, well-managed approach can be enormously beneficial to men.

The benefits of BHRT in men

This is not a miracle cure for male ageing, but when managed in the right way it can have enormous benefits, helping to restore many of the features of maleness that most men feel they are losing. 

Initially, externally provided hormones can occasionally cause headaches as the body starts to adjust to having hormones present once again. But after a couple of weeks these fade, and soon afterwards the first benefits start to appear, usually in the form of increased strength and stamina. These can be followed over the next few months by improvements in weight, muscle tone, energy levels, libido, self-confidence, mental acuity and the ability to concentrate. Linked to improved libido, sexual performance is also greatly improved. Overall, these improvements can take a whole year to develop, so some patience and persistence are needed.

The effectiveness of the treatment does, of course, vary from one man to another, with much of the variation often down to how closely they follow the prescribed regularity and application methods (described below), as well as lifestyle factors such as diet and exercise.

In principle, it is perfectly possible for a man to stay on their BHRT programme for many years, helping to maintain their maleness as well as their mental and physical health well into old age. However, being able to do this does depend on maintenance and close monitoring of prostate health. Any development of prostate damage symptoms may necessitate steps to protect the prostate, including - if necessary – scaling back of the BHRT programme. More on prostate protection below.

The male BHRT programme

At Hebe Medical I provide bio-identical hormone replacement therapy (BHRT) to men on a daily basis, following a treatment process that is highly personalised and closely monitored. The men who approach me for help are generally in their fifties or sixties, though some are in their forties. Almost without exception they complain of all the symptoms already described, symptoms that leave them feeling much less of a man than they used to be. 

The first step in treatment is an in-depth consultation that assesses their medical history (and hence any possible underlying issues), their current symptoms, and what they hope to achieve with BHRT. This is completed with the collection of a small blood sample, which is sent off to a laboratory for analysis. 

The tests establish the patient's baseline blood levels of the steroid hormones testosterone, DHEA-sulphate, progesterone and estradiol. They also measure a number of other components, most especially a protein called sex hormone binding globulin (SHBG, which binds to some of the hormones in the blood), vitamin D and prostate surface antigen (PSA). The last of these is an important measure of prostate health. 

In a middle-aged man complaining of ageing symptoms, the test results usually show them to have very low blood levels of:

• Testosterone that is free in the blood (ie not bound to SHBG)
• DHEA-sulphate
• Progesterone

Conversely, blood levels of estradiol are often raised, particularly (though not exclusively) in men that are overweight.

So a treatment programme usually consists of providing testosterone, DHEA and progesterone, to be taken daily in order to bring blood levels back up towards those usually seen in a somewhat younger man. The exact doses needed can vary enormously, however, depending on just how low the baseline levels are. A certain amount of guesswork may be needed in the early months before just the right doses are found. 

Each of these hormones has very characteristic properties, meaning that they need to be given in particular ways. Testosterone is normally given as a cream that is spread onto the forearms and so is absorbed into the body through the skin. Providing it as a capsule to be swallowed is usually rather ineffective, as it is poorly absorbed through the gut wall, and any that is absorbed is quickly destroyed in the liver. Absorption through the skin by-passes these problems. 

Both DHEA and progesterone can readily be given as capsules, but because both hormones are soluble in fats, not in water, they must be taken with some healthy fatty food, such as full-fat yogurt (any kind), peanut butteror hummus; basically any of a number of foods rich in dairy or plant oils. Furthermore, because DHEA is something of a stimulant it is best taken in the morning. Conversely, because progesterone can cause sleepiness it is best taken in the evening shortly before going to bed.

Once on the programme, further blood tests are taken after 10 weeks to check to see how the blood hormone levels and the PSA are responding, and to tweak the doses if necessary. After this, tests are repeated at least once a year, or more frequently if any unfavourable symptoms are detected. 

Finally, why 'bio-identical'? In this programme we provide only hormones that are chemically identical to those found normally in the body. In BHRT we simply replace like with like, replacing hormones lost from the ageing body with ones that are identical in every way. This is quite different from traditional HRT programmes used in women, in which some of the hormones provided are synthetic substitutes, molecules that are slightly different from the natural bio-identical hormone. This is particularly so for progesterone, frequently replaced with synthetic 'progestins', molecules that do not have all the same effects provided by the bio-identical equivelant. At Hebe Medical, I use only bio-identical hormones for both men and women.

Female hormones in the male body?

It was traditionally believed that men's sexual hormones consisted simply of testosterone, with no estradiol or progesterone: these latter two were the preserve purely of women, who conversely had no testosterone. 

This is now known to be quite untrue, and that both men and women contain all three hormones, although at very different levels, men normally having about ten times as much testosterone and far less estradiol and progesterone compared to women. The lesser known DHEA is found in both sexes. 

While it is well known that it is testosterone that gives men many of their male features, especially physical strength, energy levels, competitiveness, body and facial hair and deep voice to name just the most obvious, the role of the female hormones in men is less well appreciated. 

A certain level of estradiol is necessary to maintain health and libido, but once it becomes too high then it can cause a man to put on weight, and is recognised as one of the main factors in prostate damage. More on the latter below.

The role of progesterone remains quite controversial, many doctors still failing to recognise its importance in men. However, a growing mountain of evidence shows this hormone to be critical to the correct control of the way testosterone is processed in the body, blocking the activity of two enzymes central to prostate damage.

Protecting the prostate in men receiving BHRT

It has long been recognised in medicine that the male hormones, especially testosterone, are closely linked to the prostate swelling known as Benign Prostate Hypertrophy (BPH), which can then go on eventually to result in prostate cancer. 

However, it clearly cannot be an effect of testosterone per se, otherwise men in their twenties and thirties would be dying like flies. Instead, the problem lies in the processing of testosterone and the way this is controlled. 

In older men testosterone is very easily converted into estradiol and dihydrotestosterone (DHT), both of which are strong promoters of prostate enlargement. In younger men both these conversion processes are blocked by another hormone: progesterone. 

So any male BHRT programme that provides testosterone (and/or DHEA too for that matter) must also ensure that production of DHT and estradiol is blocked. That I do mainly with the provided progesterone, but a number of dietary supplements are also critical. These are: 

• Boron
• Zinc
• Copper
• Quercetin complex
• Beta-sitosterol
• Pumpkin seed oil

All of these supplements have been shown in a growing list of clinical research studies to be highly effective in both blocking and reversing BPH, and so are valuable tools in protecting prostate health. They will be covered in more detail in another blog, but suffice to say here that all men on my BHRT programmes are required to take these six supplements in addition to the hormones.

Putting it all together

So male BHRT is perfectly possible provided it is given in a highly personalised and closely monitored way. Such a programme usually includes the daily taking or application of three hormones, namely:

• Testosterone
• DHEA
• Progesterone

Plus a number of daily dietary supplements, as listed in the previous section, aimed principally at protecting the health of the prostate. 

Regular blood tests not only provide data about a man's starting levels but also keep a check on whether the provided hormone doses are resulting in the right blood levels. These not only give pointers as to whether the doses need to be changed but also whether each man is taking them in the right way, and whether the prostate is remaining healthy.

Provided I and each man work together as a team, the reward for them is a restoration of their previously failing maleness, something that – with the correct care and monitoring - should be maintainable for many years into the future.