Male Health

Follow me on Twitter. Seriously.

It’s been a little over five years. I wrote my first post on this blog, The Mysteries of Funny Looking Sperm, April 18, 2010. At the time, this blog was very much an experiment, and I had no idea how it would work. In my daily life, I see a lot of men with difficulties having children or other male health problems, and they don’t tell you anything about that when you take “sex ed” in high school. Lots of men share the same problems, and I would say the same things to different men throughout the day. So I thought that I would put my end of those conversations in a general way on a blog, so that men around the world with questions about male reproductive health might find some answers.

My first few blog posts came from those common conversations. I see a lot of men with male endocrine problems, so I wrote a few posts on how the endocrine system works in a man and how it can be fixed if needed. I wrote about concerns like, can a man’s underwear cause problems with his sperm? At first, I shut off comments after two weeks, but I quickly realized that many people found my posts not by reading the blog start to finish, but through a search for a specific concern. That makes a lot of sense: I do that, too. People would be coming at a post weeks, months, or even years after I wrote it. My third post on April 28th, 2010, How Clomid Works in Men, is still my most visited one with 874 comments as of today.

After a while, people started asking great questions in the comments. Sometimes I could answer them in a couple of lines in the comments section, but some required longer answers. I added posts for a few of these great questions. Understandably, although I tried to make it very prominent in the FAQ, people would still ask me medical questions about themselves and their loved ones. It’s really frustrating, but I can’t answer them. I don’t have the basic information through the web that all doctors need to make a diagnosis and treat a patient, which includes a physical examination. I need to see people in person to be their doctor.

As the blog evolved, I began posting about news events, important scientific studies, and general items of interest in male health. But most people still come across the blog by searching for a specific problem or question, and that’s the way it mainly seems to work. So for those who read a post from years past and have a question, I’ll often recommend reading the comments and other posts on the blog, as the answers are usually there.

But if you’re interested in male health, and you want a more up-to-date stream of information, then follow me on Twitter. I post pretty frequently there, often with links to important news articles about male health and the other parts of my job in science, engineering, and education. You’ll even see my human side from time to time. I’ll of course still write here on this blog when the need for more words arises.

See you in the Twitterverse!

As I’ve written before in this blog, clomiphene is an effective if off-label treatment for men with low testosterone who want to preserve their fertility. If used directly, testosterone itself actually decreases the making of testosterone and sperm in a man’s testis. Clomiphene increases testosterone production in the testis by increasing the pituitary hormones that tell the testis to make testosterone.

In the March issue of Fertility and Sterility, a journal that I co-edit with Dr. Antonio Pellicer, Drs. Kim and co-authors review the published medical literature on treating low testosterone with clomiphene and other drugs besides testosterone. They conclude that clomiphene is a safe and effective treatment for men with low testosterone and note that less than one year of treatment with testosterone is usually reversible if a man wants his fertility to return. Unfortunately, we don’t know all that much about longer treatments with testosterone, and many men who have been on testosterone for several years do not have sperm return even with other forms of treatment.

Drs Kim and co-authors give us a nice review that supports the use of clomiphene for men with low testosterone who want to preserve their fertility.

As I’ve written in earlier posts, clomiphene is a medication that a doctor can use to increase a man’s production of testosterone in his own body. (I’ve also written about how doctors can prescribe it. If you think that you’d benefit from this medication, you should see a doctor. I can’t answer personal questions about a man’s health on this blog. Medical care is always done best in person.) But clomiphene is “off-label” for use by men and didn’t go through the rigorous series of studies that the FDA mandates for a drug for a particular use.

One good question is whether clomiphene is safe for long term use by men. John Mulhall, a great doctor in New York, recently published a report in the British Journal of Urology studying the use of clomiphene for up to three years in 46 men diagnosed with low testosterone. Blood testosterone, bone scans, and symptom scores all improved, and men did not report problems with the medication.

There are limitations to this study. It wasn’t controlled, meaning that there wasn’t a group of men treated with a placebo, or sugar pill. 46 isn’t a lot of men, and three years isn’t really a very long time. But this kind of study is what needs to be done with more men and for a longer time to really determine the safety of clomiphene for long term use in men.

Clomid surely has its advantages compared to testosterone for use in men with low testosterone. It’s a pill, and other treatments are either shots or cumbersome skin applications. It also saves sperm, as testosterone itself reduces sperm production. But information about its use is less than that of testosterone, which puts men and their doctors in a kind of Catch-22. Mulhall and colleagues are to be commended for expanding what we know of the safety of this medication.

Google is an amazing place. It seems like almost everything is there. A traditional way for doctors and scientists to search published studies is by using the National Library of Medicine’s PubMed site. I use it a lot, as it contains only peer-reviewed medical studies. Google has a similar resource called “Google Scholar.” I made a Google Scholar profile, and you can see what I’ve written there. Check it out!

May blew by, and I didn’t manage a single new post.  The annual meeting of the American Urological Association and a big burst of research activity in my bioengineering lab did keep me busy, but really, there’s no good excuse, and it’s time to blog again.

One very active area of this blog is How Clomid Works in Men, with over a hundred comments to date.  I’m grateful to Robert for inspiring this post.  His question is, are there medications that decrease estrogen?

To review how the pituitary controls the making of testosterone in the testis, testosterone is converted to the female hormone estrogen, and rising levels of estrogen tell the pituitary to make less luteinizing hormone (“LH”).  The role of LH in a man is to stimulate the testis to make testosterone, and as the pituitary sees more testosterone in the blood through the lens of estrogen, it tells the testis to make less testosterone by reducing LH.  I likened this negative feedback system to a thermostat and a heater: as the room becomes hotter, the thermostat turns down the heater.  Clomiphene binds tightly to the pituitary, (and hypothalamus for you biological sticklers), and tricks the pituitary into thinking less estrogen is bouncing around in the bloodstream.  The pituitary labors to make more LH as a result, and the testis makes more testosterone.  The drug tamoxifen works in a similar way.

But Robert’s question hinted at another way to trick the pituitary: there is a way to decrease estrogen directly so that the pituitary sees less of it and makes more LH.

The enzyme aromatase turns testosterone into estrogen.  Drugs like anastrozole and testolactone block aromatase, causing estrogen to decrease in the blood.  The pituitary makes more LH as a result, and the testis produces more testosterone.  If a man has low testosterone and high estrogen, these drugs can simultaneously increase testosterone and decrease estrogen. In a study published in the Journal of Urology in 2002, doctors Raman and Schlegel report evidence that anastrozole seems to work a little better than testolactone, at least in terms of increasing sperm production.  In that study, the doctors also suggest that these drugs are best used if the ratio of testosterone is less than ten to one.

As I wrote in my post on How Clomid Works in Men, all of these drugs are off-label for use in the male, meaning that the Food and Drug Administration didn’t approve their use in men.  That doesn’t mean that they can’t be used.  It means that doctors need to tell patients what we know about these drugs, allowing for an informed decision on their use.  It also means that many of the questions we have about these drugs don’t have answers.  A good question about aromatase inhibitors in men is whether estrogen plays an important role in some health concerns in men, and if it is decreased for a long period of time, can other health problems occur?  We don’t know.  My current practice for prescribing aromatase inhibitors is mostly to limit their use to male fertility, and to stop the medication as soon as possible.

So there you have the two basic ways that pills can trick the pituitary into telling the testis to make more testosterone.  Thanks, Robert!