Andropause Mastery

Question 1 of 13

1. Question
Factors that may naturally decrease aromatase (choose incorrect answer):
- Correction of obesity
- Reduction of estrogen levels may be the tip-off that testosterone treatment levels are excessive
- Iodine (increases estrogen metabolism)
- Calcium D-Glucarate 500–1000 mg/day for detox
- Zinc 50 mg (if zinc-deficient)
- Cruciferous vegetables (DIM is poorly tolerated by males in high dosages as it is also an anti-androgen)
- DIM is better tolerated by females
- Trans-Resveratrol 500 mg daily
- Reduction of inflammation (COX 2 inhibitors ie Curcurmin or treatment of infection)
- Control of excess testosterone dosing, particularly hCG that stimulates testicular production plus peripheral conversion
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Question 2 of 13

2. Question
Aromatase inhibitors: Most common available in the US (choose incorrect answer):
- Arimidex 1 mg – non-steroidal, though dosages for males should be compounded to provide 0.1–0.2 mg twice weekly
- Femara 2.5 mg – non-steroidal, very strong, perhaps preferable for morbidly obese men; never prescribe more than 1/2 tablet weekly in cases of obesity
- Aromasin 25 mg – steroidal (do not use this at all)
- Topical Crysin 50 mg/cc applied scrotally is an alternative (stains skin yellow)
- Drug holiday from aromatase inhibitors is advisable q 3–4 weeks to let the body eliminate aromatase suppression and reverse possible aromatase accumulation
- A combination of turmeric and cayenne, 3 mg each, twice daily will suppress aromatase as well as any pharmaceutical in most men
- If estradiol drops below 15 from aromatase inhibition, d.c. aromatase inhibitor and consider treating man with estradiol
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Question 3 of 13

3. Question
Aromatase inhibitors (choose incorrect answer):
- Only use low doses of anastrozole – 0.1–0.2 mg 2–3 times weekly for most indicated uses – never 1 mg doses.
- For estrogen levels above 30, you may have to use higher dosages of anastrozole, even up to 1–2 mg daily.
- An aromatase inhibitor “drug holiday” for 2–4 weeks is recommended after 3 months to see if the indications or testing indicates continued need.
- It is possible to totally turn off aromatase after 1 year of use. After 1 year, there has been only marginal estrogen production even with maximal stimulation. In that case, low dose replacement E2 was prescribed with good restoration.
- It can be optimal to use natural approaches along with the aromatase inhibitor.
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Question 4 of 13

4. Question
Clomiphene and analogues: Enclomiphene, Tamoxifen.

Clomid Stimulation Test (choose incorrect answer):
- Used to test for hypothalamic/pituitary unit functioning in “younger” individuals <65 yrs
- Clomiphene can also work quite well in the older age groups >65
- Usual dosage for stimulation test is low dose of Clomid, 25 mg (1/2 tab) hs for 7 days
- Check pre and post FSH/LH, testosterone total, E2
- Positive responses: FSH/LH variably increase if hypothalamus/pituitary unit intact
- Positive responses: In testosterone (> 50%ile , or even 25-30% free T), testes OK
- Use CFT nomogram to calculate free T using total T + SHBG
- If testosterone reaches target level CFT, Clomiphene may be used for treatment
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Question 5 of 13

5. Question
Clomiphene for treatment of hypogonadism (choose incorrect answer):
- 86 hypogonadal men (T <300ng/dL) treated with 25–50 mg 3x weekly for 19 months with normalization of testosterone to mid-normal ranges (550ng/dl +/- )
- Some individuals respond well to 10–15 mg 3x per week
- Some individuals require up to 100 mg or >5x per week
- Very few adverse side effects seen with these dosages
- There is a visual side effect possible with 50 mg and higher: light flashes and even worse if excessive dosages persist
- Improvement in ADAM Questionnaire on at least 3 items
- With treatment, improved energy, strength and stamina
Correct

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Question 6 of 13

6. Question
Clomiphene boosting (choose incorrect answer):
- Clomiphene treatment is more successful when combined with simultaneous testosterone replacement
- Clomiphene may increase T and improve sexuality in PADAM (partial androgen deficiency in aging males) – Andre Guay, MD at Lahey Clinic
- Clomiphene at higher doses (50 mg) may block estrogen receptors in the sexuality centers in the pre-optic area
- Low doses – Clomiphene SR caps 10–25 mg 3x weekly seems to work best
- May work up to 50 mg twice weekly if needed
- If no good clinical response (about 1/3 cases), then switch to CG or replacement
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Question 7 of 13

7. Question
Boosting with Clomiphene and hCG, a case report (choose incorrect answer):
- Trial 1 with clomiphene was not an adequate response
- Trial 2 with 500 units of hCG brings testosterone up to an adequate level with good clinical results
- For best results, testosterone replacement should also be added
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Question 8 of 13

8. Question
Reported adverse effects of Clomiphene (choose incorrect answer):
- The most common effects are visual aberrations usually seen at the higher doses used in infertility 100+ mg.
- Occasionally visual symptoms are reported by patients during the 25 mg daily dose during the “Clomiphene Test”. This nullifies any further use in that individual.
- More serious retinal macular degeneration has been reported after prolonged use.
- Visual changes with Clomiphene also nullifies any trial of hCG stimulation.
Correct

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Question 9 of 13

9. Question
Prolactin can affect all aspects of the HPT axis (choose incorrect answer):
- Aromatase activity
- Sexual libido and response
- When libido is reduced with elevated prolactin levels, it can be balanced by increasing testosterone dosages
- When men have an orgasm, their prolactin levels rise for a certain period, resulting in diminished libido and a "refractory period" of libido recovery
- Sexual interest returns in men when the prolactin levels come down after refractory period
- Prolactin levels should be assessed on initial serum testing as well as selected follow-up testing if warranted
- Prolactinomas represent a significant correctable adenoma that may resolve the issues
- Normal or borderline high levels may be treated with low doses of dopamine agonists with improved sexuality
- These changes may represent dysfunctional circadian rhythm for many reasons, i.e. sleep apnea, chronic illness, aging changes
Correct

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Question 10 of 13

10. Question
Effects of high prolactin (choose incorrect answer):
- Increased estrogens output
- Decreased LH response to GnRH
- Decreased testosterone output
- Increased SHBG
- Decreased libido
- Increased erectile dysfunction
- Increased refractory period after climax
Correct

Incorrect
Question 11 of 13

11. Question
Factors that increase prolactin secretion or rhythmicity (choose incorrect answer):
- Low dopamine
- Increased TRH/TSH
- Hyperthyroidism
- High estrogen
- Renal insufficiency
- High cortisol/stress
- Low zinc
- Increased iNOS
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Question 12 of 13

12. Question
Treatment of Prolactin excess (choose incorrect answer):
- Testosterone replacement in robust dosages will lower prolactin
- Bromocriptine (generic), which also inhibits excess prolactin and increases insulin sensitivity and reduces SHBG – 2.5 mg oral tablets 1/2–1 tablet daily in the AM on arising
- Higher levels of Prolactin >35 ng/ml require MRI/CT scan of the pituitary gland and require full dopamine dosing with Cabergoline 0.5mg 1–2x weekly (referral required)
- Lower “high normal” (after 9AM) >8 ng/ml can be treated with compounded Cabergoline 0.1 mg 1–2x weekly until levels are in the 1–5 ng/ml range
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Question 13 of 13

13. Question
Peptides and non-peptide secretagogues (choose incorrect answer):
- GHRP2 and GHRP6 alone or in combination with Sermorelin (all injectable and short acting) has been disappointing in my experience with few reporting specific clinical improvements.
- MK677 – Ibutamoren is a non-peptide oral secretogogue ghrelin mimetic that has been shown to provide sustained increased GH/IGF1 increases for over 24 hours. Research shows increased lean mass but without changes in strength. Available through compounding pharmacies.
- HH6977, a common meat peptide, has shown to be quite effective.
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Andropause Mastery

Quiz 16: More on Aromatase Inhibitors. Boosting HPT Axis: Clomiphene, Prolactin

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