Dr. Weyrich's Naturopathic Functional Medicine Notebook is a collection of information on topics of interest to Dr. Weyrich that may be of interest to the world wide audience. Due to limitations of time, not all information that Dr. Weyrich knows or would like to further research is published here. Dr. Weyrich welcomes financial contributions to support specific research topics, as well as copies of non-free access journal articles for him to review on a topic. Constructive criticism is also welcome.


Overview of Male Sexual Dysfunction

Testosterone benefits libido in both males and females (although therapeutic levels are different) [Friedman2013, pg 63]

Although many men attribute erectile dysfunction to low testosterone levels, in many cases low thyroid function is the underlying cause [Starr2005, pg 149].

Another significant cause of ED is atherosclerosis of the arteries serving the genital area, which reduces blood flow to the region. This is yet another reason why men should keep their cholesterol under control.

The good news is that correcting low thyroid function also tends to correct high cholesterol.


Etiology of Male Sexual Dysfunction

There are many inter-related causes of low testosterone and male sexual dysfunction. These include:

Excess Cortisol

  • Corticosteroid drugs such as prednisone.
  • Stress increases cortisol production and can deplete DHEA (which is called pregnenolone steal) [which can directly decrease testosterone precursors].
  • Increased cortisol can suppress TSH, decrease conversion of T4 to T3, and increase conversion of T4 to inactive reverse T3 [low free-T3 causes hypothyroid symptoms, see below].
  • Increased cortisol can increase production of Sex Hormone Binding Globulin (SHBG) [which reduces free testosterone].
  • Increased cortisol can increase blood glucose, which is converted to visceral fat [see below].
  • Increased cortisol can reduce pitiutary production of LH [see below].

Hypothyroidism

Optimizing free T3 can double free testosterone.

  • Stress [see above].
  • Hashimoto's Thyroiditis.
  • Nutritional Deficiencies [Iodine, tyrosine, iron, zinc, etc - test don't guess!].
  • Surgical destruction of thyroid gland.

Excess alcohol intake

  • Can suppress hypothalmus/pituitary axis [see below].
  • Promotes visceral fat deposits ("beer-belly") [see below].

Excess Visceral Fat Deposits (Obesity)

  • Visceral fat contains the enzyme aromatase that converts testosterone to estrogen.
  • This reduces free testosterone and adds unhealthy levels of estrogen.

Hypothalamic Dysfunction

  • Low production of gonadotropin-releasing hormone, GnRH.
  • GnRH is needed to stimulte the pituitary to make luetnizing hormone, LH [see below].
  • Excess estrogen, progesterone, or testosterone can suppress GnRH via a negative feedback loop.

Pituitary Dysfunction

  • Low production of luetnizing hormone, LH.
  • LH is needed to stimulate testosterone production in the testes.

Overtraining

Exessive exercise associated with body-building or performance training can suppress sexual function, partly as a result of increased stress [see above]. This phenomena is well known in women, where loss of menstrual function is one component of the "female athletic triad".

Atherosclerosis

Atherosclerosis of the arteries serving the genital area limits blood from flowing into the penis to enlarge it.

Autonomic Nervous System Compromise

Proper coordination of both the sympathetic and parasympathetic nervous systems is necessary to produce erection and ejaculation.

  • Problems in the spine can prevent proper functioning or one or both of these parts of the nervous system.
  • Metabolic problems such as diabetes can damage small nerves controlling erection and ejaculation.

Sleep Disorders

  • Reduces GnRH [suppresses hypothalamic-pitiuitary function]
  • Sleep apnea
  • One week of sleep loss can reduce testosterone production by 15% [Leproult2011].

Inflammation

  • Increased levels of inflammatory mediators such as IL-6 reduces testosterone levels [Maggio2008].

Drugs

  • Statins [reduce production of cholesterol and all other steroid hormones including testosterone] [Neel2019].
  • Fibrates [reduce absorption of cholesterol] [Neel2019].
  • Corticosteroids such as prednisone [see Excess Cortisol above] [Neel2019].
  • Opiates.
  • Anti-anxiety medications such as benzodiazepines (e.g. Valium) [Neel2019].
  • Anti-depression medications such as SSRIs (e.g. Prozac), dopamine antagonists, tricyclics, monoamine oxidase inhibitors (MAOIs), and lithium [Neel2019].
  • Blood pressure medications such as spironolactone, beta blockers [Neel2019].
  • Antipsychotics [Neel2019].
  • Cetrorelix/Cetrotide a gonadotropin-releasing hormone (GnRH) antagonist used to block FSH and LH production.
  • H-2 blockers, especailly cimetidine/Tagamet [Neel2019].
  • Anticonvulsants [Neel2019].
  • Estrogens and progestins, including birth control pills [suppress GnRH production].
  • Sulfonylureas [suppresses testosterone and thyroid]
  • Anti-androgens to treat hair-loss, prostate cancer, or hirtuism (e.g. finasteride/Proscar, dutasteride/Avodart, flutamide/Eulexin, nilutamide/Nilandron/Anandron).
  • Ketoconazole and some other anti-fungal drugs.
  • Nonsteroidal antiinflamatory drugs ???

Envionmental Endocrine Disruptors

  • Plastic products:

    Avoid when possible, and especially do not cook in plastic containers.

    • BPA [additive in polycarbonate (#7) plastics found in cans, bottles, and food utensils] [EWG2013].
    • Pthalates [additive in plastic food containers and wrap, chilren's toys] [EWG2013].
  • Water contaminants:

    Use water filter or glass bottled water from safe sources.

  • Food contaminants:
    • Soy, and other phytoestrogens.
    • Mercury [many fish] [EWG2013].
  • Other:
    • Fire retardants [may be in dust] [EWG2013].
    • Dioxin [hard to avoid] [EWG2013].
    • Perflorinated chemicals (e.g. PTFE = Teflon) [persistent in the environment] [EWG2013].
    • Organophosphate pesticides [EWG2013].
    • Glycol esters [solvents and cosmetitcs] Glycol esters [EWG2013].

Electromagnetic radiation

[Gye2012] have collected a summary of many studies of the effect of electromagnetic field (EMF) on reproductive function in vivo and in vitro. While effects were demonstrated, the data presented was insufficient to evaluate the effects of real-world exposures; further research (and study of the referenced primary literature) is necessary to establish sufficient context.

However, Dr. Weyrich feels it is safe to say that sitting with a laptop on ones lap for prolonged periods of time may not be a good idea; however, since the strength of EMF fields decays with the cube of the distance, placing the laptop on one's desk would significantly reduce the exposure.

Light polution

Light polution disrupts circadian, lunar, solar, and other natural rhythms. Modern society has been said to live in "endless summer" due to the increasing use of electric lights and communication devices. This disrupts hormonal cycles. In particualar, the use of cell phones in bed disrupts hormonal rhythms and also tends to be a "big turn-off."

Inadequate "Earthing

The Earth itself generates low frequency electromagnetic fields that have been shown to affect fertility and other aspects of wellbeing. This benefit is prevented when an individual's body is insulated from the ground.

Walking barefoot (in safe areas) and sleeping on a specially grounded mat may therefore benefit sexual well-being of both men and women.

Other

  • Elevated insulin may contribute to erectile dysfunction, or it may simply be an effect of diabetes mellitus type II or syndrome X.
  • According to [VIVO2019], "leptin appears to be a significant regulator of reproductive function. These effects are probably due in part to the ability of leptin to enhance secretion of gonadotropin-releasing hormone from the hypothalamus, and thus luteinizing and follicle-stimulating hormones from the anterior pituitary."
  • [Elsaied2019] have shown that "decreased adiponectin and testosterone are associated with [erectile dysfunction] in [thype 2 diabetes mellitus]," but did not correlate with with the scores of international index of erectile function (IIEF), possibly to a small number of patients studied.
  • Various vitamin, mineral, protein, and fat imbalances or deficiencies can disrupt many components of the endocrine system. Note that in some cases, even though there is adequate nutritional intake, absorption my be prevented by factors including certain diseases (e.g. celiac sprue) or drug intake (e.g. antacids or certain cholesterol lowering drugs).
  • Smoking or other Nicotine Intake. Nicotine is a vasoconstrictor that can reduce blood flow in many parts of the body, including the genitals.
  • Marijuana and other recreational drugs.
  • Depression, interpersonal relationship,and other psychological factors.

Diagnosis of Male Sexual Dysfunction

Testosterone can be easily measured using blood, urine, or saliva. Although blood testing is the "gold standard," the use of urine testing can give far more information about the metabolic balance between all the steroid hormones that interact with testosterone.

Dr. Weyrich's initial lab testing plan includes:

  • CBC, CMP, Lipids, Hemoglobin A1-C
  • Dried urine screening of thyroid (T4, T3), sex hormones (testosterone, estrogen, progesterone, DHEA), and cortisol circadian rhythm.
  • Hormone-related blood testing: TSH, LH, prolactin, Sex Hormone Binding Globulin (SHBG)
  • PSA
  • Vitamin D
  • Ferritin
  • hsCRP, Homocysteine

Follow-up and testing as indicated, including possibly:

  • Additional thyroid panel (T3, fT3, rT3, TPO, Thyroid antibodies)
  • IgG Food Allergy testing
  • Spectracell Micronutrient Assay
  • Digestive & microbial stool analysis
  • Free and total Testosterone, free PSA
  • Etc.

Treatment of Male Sexual Dysfunction

Treat the cause. This is a multifactorial problem, and an individualized and prioritized treatment plan is necessary. Do lab work as necessary to identify causes.

Testosterone is regulated by the DEA as a controlled substance, due to the dangers of potential misuse. Administration of testosterone by topical creams/gels or injection is a last resort after addressing all correctable causes of low testosterone. Oral testosterone therapy is no longer recommended for males due to liver toxicity (low dose oral testosterone may be tolerated by females, but topical is more appropriate).

When administering testosterone, a number of potentially serious side effects must be monitored:

  • Excess testosterone may stimulate production of erythropoetin by the kidneys, which can cause over-production of red blood cells (erythrocytosis), blood hyperviscosity, and increased risk of cardiovascular events. CBC must be monitored and hematocrit kept within safe range by either reduction of testosterone dose or regular blood donation.
  • Excess testosterone may be converted to estrogen by an enzyme called aromatase that is especially found in fat cells and the liver. This excess estrogen can promote gynecomastia ("man boobs"), promote deposition of additional abdominal fat, and irritate the prosate (increasing risk of prostate cancer). Estrogen levels must be monitored and kept within safe range by either reduction of testosterone dose, drugs that suppress aromatase activity, or increasing liver detoxification capacity with nutritional support and herbs.
  • Exogenous administration of testosterone suppresses the hypothalamic production of GnRH, the pititary production of LH and FSH, and can cause irreversible atrophy of the testes (hypogonasim) and infertility (loss of the ability to produce sperm). To prevent or mitigate these problems, testosterone replacement must have "holidays."
  • Excess testosterone may cause either male pattern baldness or promote overgrowth of body hair (hirtusism). These effects may be permanent.
  • Excess testosterone may cause acne or changes in personality (but so can low testosterone levels).
  • When using topically applied testosterone, care must be taken to prevent transfere to spouse, children, or pets.

ICD-10 Codes related to Male Sexual Dysfunction


References for Male Sexual Dysfunction