Clinical use of aromatase inhibitors
Muscular Development|January 2021
Contrary to expectations, medical professionals (such as physicians and researchers) learn from folklore developed within (sub)cultures, or from impassioned pursuits by laymen affected by a specific pathology.
By Daniel Gwartney, M.D.

For example, there is no ICD-9/10 (International Classification of Diseases) coding for “biceps peak deficiency” or “squatopenia.” Those are matters of choice, not health. Yet, medicine is trailing bodybuilding lore in developing treatments for androgen (testosterone) deficiency or insufficiency due to certain causes. The protocols developed (through trial and error) by drug-enhanced bodybuilders have provided observations upon which treatment of testosterone deficiency due to aging, or other causes that affect the regulatory function of the hypothalamic-pituitary axis, can be guided.

As men age, changes in endocrine and metabolic balance occur that evoke a condition of lessened health, if not outright chronic disease. These changes eventually progress to significantly contribute to recognized chronic disease states (e.g., obesity, metabolic syndrome, cardiovascular disease). The focus of “men’s health” has been on testosterone status, specifically the circulating concentration of total testosterone. While a step forward from the (actually stated, but paraphrased here) 1940s-50s stance of the American Medical Association that men should just age and die, and society does not need old men with boners or a young man’s sex drive, there is room (lots of room) for improvement.

Testosterone Insufficinecy

The single-minded focus on testosterone has numerous shortcomings; most are outside the scope of this article. One issue that is only recently being addressed is “if and how” to treat men with marginal “normal” testosterone, yet complaining of low (subphysiologic) testosterone-related symptoms. This should be defined as “testosterone insufficiency,” much like the accepted vitamin D3 state of insufficiency that precedes full-blown deficiency. The lower cutoff for “normal” peak testosterone is between 280-350 ng/dL, depending upon the guidelines the clinician chooses to follow. 1 Remember, it is measured at its highest point of the day – it could be like having your credit score checked right before you take out a big loan, max your credit cards and quit your job.

Most guidelines recommend confirming low testosterone readings with a second test – that is the equivalent of a car dealer checking with a second lender if you get rejected on your first auto loan. So, what about the man who has a total testosterone (never mind that free testosterone correlates better with the signs and symptoms of deficiency) of 360 or even 400, perhaps only on the second blood draw? Keep in mind, the “normal” range extends all the way to 980-1,100 ng/dL, depending upon the lab and method used. The average total testosterone value for healthy, non-obese, young men is 700 ng/dL. 2 So a man is considered normal if his testosterone is half the value of the average healthy man. This places him in the bottom 2.5 percent of all men, if the statistical model was valid. There are few people who challenge the “standard of care” reference range. Consider that when hypothalamic-pituitary suppression due to metabolic dysfunction and/or Leydig cell dysfunction is treated, that most men, even older men, respond to the 450-550 ng/dL range or higher. 3,4 This level of total testosterone is associated with improved glucose tolerance/ insulin resistance, and other metabolic signs in hypogonadal men. 5

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