Men's Health

Health specific to men represents a significant portion of health burden. Life expectancy for men is up to 8 years shorter than women. Behavioral and psychological elements do play their part, but there may still be room for developing a more robust system for treating men's health. Erectile dysfunction, changes in testosterone, and prostate issues can be difficult for a lot of men to discuss even with a healthcare provider, but these issues can lead to physical and emotional problems including a group of symptoms labeled LUTS or lower urinary tract symptoms. It's easier to avoid difficult or awkward conversations and examinations when you don't go through a medical professional, but this can lead to untested practices and even exposure to dangerous medications or toxins from unregulated supplements. Today on the Integrated Pharmacist Podcast, I'd like to go through medicine specific to men's health. Hopefully, we can find a way to guide patients to healthy options that are safe and effective while allowing them to guard their dignity.

This has been an eye-opening topic for me. I was really able to reflect on how I think about my own health and what might help me overcome my personal roadblocks. In general, men don't consider going to the doctor until there is a significant problem. Although a man might be consistent and regular for maintaining his car, he may not use the same kind of attention to maintaining his own health. Two major motivators seem to influence men to pay attention to their health - facing mortality and threats to their ability to perform. This means that compared to women, most men need a diagnosis of a life threatening disease before they'll do something to change their health. Either that or we need to see how changing will enhance our ability to act whether that be as a provider, a lover, a warrior, or even as a friend.

As a man in my early 40's, I used to dread my first prostate exam. I am glad to announce that according to UpToDate, a medical database, it is currently unadvised to perform the digital rectal exam for BPH (benign prostatic hyperplasia). You can go to your allopathic doctor confident that they will likely not perform that uncomfortable test. This is due to its low sensitivity and specificity (51% and 59% respectively) which means about 1/2 the time the doctor thought there was a problem there wasn't and about 1/2 the time the doctor thought there was no problem, there actually was! About 1 in 4 men will develop symptoms of BPH, but there is still some debate on when and who should get a blood prostate-specific antigen test to screen for BPH and prostate cancer. Also, there are imaging tests that are much less invasive that seem to have more accurate diagnostic ability.

Testosterone levels naturally decline with age. More than 1/2 of all men 40-70 years old complain of erectile dysfunction. The major health issues that plague men include cardiovascular disease, hypertension, hyperlipidemia, diabetes, smoking, obesity, and sedentary lifestyle. Not only do they contribute to the shorter life expectancy, but they also contribute to erectile dysfunction and decline in mood. As we dive into the studies, I'd like to go over lifestyle adjustments, complementary health modalities, and then supplements and herbs.

Exercise turns out to be an excellent lifestyle modification for men. According to a meta analysis,

exercise, education, and peer support are the lifestyle interventions that seem to help men the most toward quality of life changes. Following that analysis, a study published in 2009 followed 42 Nigerian men who suffer from high blood pressure and ED. They were given methyldopa to control blood pressure, because it doesn't interfere with normal changes in blood pressure while exercising. Half the men were given a moderate cardio exercise routine while the other half was asked not to perform any strenuous activity. Not only did they find a better control of blood pressure, but they also found improvement in ED for patients who had the 8 weeks of exercise. This study is important, because it demonstrates that doing physical activity serves more than one purpose. Although it was a small study with a concentrated racial profile, it was preceded by a number of other studies that demonstrate similar results. I think it's important that people pick the kind of movement and exercise that suits them, but also stretches them. It should be something that helps to build muscle and give their heart a workout, too. But it should also be enjoyable, otherwise, it will be difficult to keep it going.

This next trial is a good demonstration of a mismatch in exercise. The Journal Evidence-Based Complementary and Alternative Medicine published a study in 2012 looking for the effects of Taichi on BPH and testosterone. It was designed based on research suggesting that exercise can be beneficial for men's health. They wanted to see if taichi specifically could have similar results. The study researchers used the International Prostate Symptom Score (IPSS), which is a standard test used world wide with high reliability. They based number of participants on preceding trials, but from the presented information, it sounds like they had difficulty recruiting participants. They also experienced a 50% dropout rate which was highly unexpected. Despite these shortcomings, they were able to detect significant improvement in IPSS and quality of life for patients taking taichi. They also so an increase in serum testosterone in the experimental arm. What I learned from this trial is that taichi can potentially be good for testosterone and BPH, but may not be a good match for a lot of men. The benefit of taichi seems to be its ability to engage in the autonomic nervous system. This could potentially be combating the effects of stress on male patients.

Of course, there is a specific exercise that has been researched for lower urinary tract benefits - pelvic floor exercise. This is basically the gender-neutral term for Kegel exercises designed to help pregnant women. As one of my teachers proclaimed, "Kegels for all! Kegels all the time!" To describe it a little better, it's the muscles you might flex to retain flatulence. It also happens that this group of muscles are used to complete urine evacuation, it helps retain blood during erection, and it pumps during ejaculation. A study published in 2005 took 55 men over the age of 20 who experienced 6 months or more of erectile dysfunction. The men in the control arm of the study were given lifestyle modification education including smoking cessation, reducing alcohol consumption, reducing weight, getting fit, and avoiding bicycle saddle pressure. The men in the experimental arm got this education, but then they were also taught pelvic floor muscle exercises guided with biofeedback. These men were instructed to perform 2 sets of 3 reps for these exercises in 3 different positions - in other words, 3 contractions while laying down, 3 while sitting, and 3 while standing two times a day. After 3 months, the men in the control arm (all of whom received no benefit to that point), were crossed over to the treatment arm. Forty percent of participants (after intervention) regained normal erectile function with an additional 35.5% experiencing improvement. A side benefit of these exercises was improvement in post-urination dribble.

A meta analysis published in 2017 acknowledges the effects of acupuncture for BPH. Eight studies comparing acupuncture treatment against sham acupuncture demonstrates statistical significance on the IPSS test. The review covered a total of 661 men. Some studies had short term results (4-6 weeks) while others included longer-tern results (6-18 months). Although evidence did lean in favor of acupuncture across the board, ultimately, the evidence only supported short term benefits. The challenge of acupuncture, like I've posted before, is the fact that there are about as many ways to do acupuncture as there are acupuncturists. It's also difficult to blind studies not only on the participants' side, but also on the practitioner's side. There are various ways of creating a sham treatment, but there are complications with each method - whether they use short needles, non-meridian points, or some other method, there is still potential of having some effect outside of placebo. My advice for this method would be to encourage patients who already have an interest, but I don't think it's something I would automatically recommend for BPH patients.

Now, I'd like to move on to oral products designed for men's health. A substantial trial was performed in the early 1990s for saw palmetto. Over 1000 men were included in the trial and they were given either 160mg saw palmetto twice a day or finasteride 5mg once a day. They did use a placebo to mask which treatment the participants were on. The primary outcome of the trial demonstrates that self-reported symptoms improved equally in both arms. Interestingly, the finasteride group had overall better urine peak flow after 6 months, but the saw palmetto group experienced better sexual function. This trial did explain the slight difference in known mechanism of action - finasteride is competitive 5-alpha-reductase-inhibitor whereas saw palmetto is non-competitive. Although there appeared to be higher levels of dihydrotestosterone -the chemical accused of increasing prostate size - in the saw palmetto group, the patients still see similar improvement in symptoms and quality of life. This tells me that something else is going on that allows men on saw palmetto to enjoy higher levels of sex hormone while circumventing the negative effects of it.

Although that is a rather old trial, it still represents the foundations of saw palmetto use today. Since then, smaller trails have demonstrated that combination herbal products tend to out-perform saw pametto alone. In my searching, it looks as though individual ingredients don't have the same benefit separately as the combinations do. There seems to be a synergistic relationship among several herbs traditionally used to help with LUTS. I found a meta analysis that reviewed 6 different phytotherapies for BPH: saw palmetto, Africa wild potato, rye, pygeum, stinging nettle, and acorn squash. The analysis found that saw palmetto either by itself or with other herbs have shown clear benefit for BPH (of

course, the reference the trial I just covered). African wild potato and rye also have growing evidence to suggest benefit for BPH. Despite extensive trials, pygeum has not shown much benefit alone. In combination with saw palmetto, however, it does outperform saw palmetto alone. The same goes for stinging nettle and acron squash except there just isn't enough research covering those therapies alone. Ultimately, the study found all these therapies to be well tolerated, and relatively cheap. As far as recommendations go for prostate health, any of these herbal products would be a safe bet as long as it has saw palmetto in it.

A similar meta analysis published in 2019 strove to find phytotherapeutic changes in serum testosterone and sperm characteristics. Searching a broad range of herbs, nurtaceuticals, and whole foods, they found some interesting results. This report found tribulus may have improved sperm parameters in patients with idiopathic infertility, but that paled in comparison with 5 grams of velvet bean seed daily for 12 weeks. It reports promising results for maca, long Jack, velvet bean, ashwagandha, and fenugreek in increasing serum testosterone with the largest increase seen in a study where participants took 5 grams of velvet bean seed and ashwagandha root daily for 12 weeks. The study also proposed foods that show promise for men's health including pomegranate, tomato, onion, garlic, chili peppers, cinnamon, ginger, and curcumin. The researchers also proposed using zinc and vitamin D to extend the benefits of phytotherapies.

Speaking of vitamins, a meta analysis published in May of 2020 included 8 observational studies looking at vitamin D in relationship with erectile dysfunction. Their findings concluded that there is a correlation between vitamin D deficiency and severe forms of ED regardless of testicular function. A single trial of overweight men that suffered from low testosterone and low vitamin D did see a improvement in androgens with participants taking vitamin D compared to placebo. However, this does not play out in otherwise healthy men. Another meta analysis found a significant role for selenium in prostate cancer prevention. Looking at 10 studies specifically, the combined relative risk demonstrates strong evidence that supplementing with selenium can reduce the risk of contracting prostate cancer.

I found a trial studying the effects of zinc on testosterone. This trial published in 1996 was a mixed trial. They performed a cross-sectional analysis of 40 men ages 20 to 80 looking at the relationship between cellular zinc and serum testosterone. Seeing a positive correlation, they then took 4 young men average age of 27 and restricted their zinc intake for 20 weeks. Serum testosterone dropped significantly across the 20 weeks. Finally, they took 9 elderly patients average age of 64 who had mild zinc deficiency and supplemented their diets with zinc gluconate. 6 months of supplementation demonstrated an average doubling of serum testosterone.

This has been an exciting and informative episode for me. I don't have diabetes or cardiovascular disease. I have stress, but I feel like I manage it pretty well. But I am a man. And men's health does concern me on a basic, personal level. I felt much more personally invested in this episode. So let's take a look at what we learned. Basic lifestyle modifications include reducing alcohol, smoking cessation, weight reduction and good eating habits. Physical activity can really be beneficial for psychological and physiological transformations. Although taichi can specifically help with testosterone and BPH, but the patient has to be interested in it to get that benefit. Kegels! Kegels for all! Kegels all the time! Or at least flexing those pelvic floor muscles a couple times a day can help with positive male function. If someone is interested in acupuncture, there is limit evidence to support its use, but it's not something I would try to convince someone to use. As for supplements, male patients should make sure their vitamin D and zinc levels are optimized. Regular selenium supplementation can help prevent prostate cancer. I am highly interested in finding a velvet bean supplement, but until then a good ashwagandha supplement can help with a number of men's health issues. Of course, a combination product including saw palmetto and potentially stinging nettle or pygeum can help with prostate health while improving sexual satisfaction.

Maybe it's just me, but I get the sense that men today are under attack more than any other time in history. From the toxic masculinity movement to changes in social norms, we've moved away from what we know to be good for general men's health. And the western medical approach doesn't seem to be as attractive to men as it is to women. I hope in the near future to help bridge this gap. I want to help men - specifically fathers - take charge of their health and do the things that benefit themselves so they are more able to care for the ones they love. I see the need and feel it within myself. If you or someone you know is a father who feels like there isn't time to consider personal health, please reach out to me. I will be developing a program in the near future to help stressed out fathers have happier, healthier lives. I know there are others trying to help men be better, too. I would point anyone interested in supporting positive masculinity to the work of Isaac Cotec called HeroRise. He used his artwork to develope a card deck that can be used as a tool for recognizing and developing positive expressions of masculine archetypes. You can find his work at www.herorise.us.

Thank you so much for listening. Like I said, this was an important episode for me. I hope you learned something beneficial, too. It helps me to grow my podcast if you leave a rating and review - specifically on apple podcast, but wherever else ratings are an option as well. If you have questions, concerns, or comments, please reach out to me directly at integratedpharmacist@gmail.com. Please join me again next time on the Integrated Pharmacist Podcast.

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