Men’s healthMen health starts with the usual health considerations that apply to everyone, both men and women. Generally it would be sensible to consider routine screens for diabetes, cholesterol and blood pressure. Above 50, it would be good to consider screening for colorectal cancer as well. This article will consider andropause or the inadvertent drop in testosterone levels with age. Why does testosterone level drop?Testosterone is produced by the testicles. Testosterone produced by the testicles is released into the blood. Blood contains sex binding hormone globulin (SHBG) which binds to testosterone. This binding inhibits testosterone function. Whatever testosterone that is not bound is considered free testosterone or active testosterone. Active testosterone is the testosterone that produces the effects we are familiar with testosterone. The bound testosterone does not produce the same effect.With age, SHBG levels increase. SHBG levels also increase with obesity and lack of exercise. With this increase, there is less active testosterone. Interestingly sperm counts are less affected by age.Does testosterone supplementation help?This is controversial. Generally men with testosterone levels less than 8nmol/L may consider supplementation of testosterone. A noticeable benefit was a moderate increase in libido in men. However the other benefits studied such as physical activity, cognitive function were more inconsistent. Overall testosterone supplementation cannot be recommended purely for improvement of physical activity and cognitive function.Are there any side effects of testosterone supplementation?Studies on patients who were on testosterone supplementation found that they had a higher blockages in the blood vessels of the heart. FDA has since required manufacturers of testosterone products to state that potential increase of heart attacks and strokes are side effects of testosterone products.There are also theoretical concerns of prostate cancer. Treatments for prostate cancer involve using anti-testosterone drugs. Hence it stands to reason that using testosterone might increase the risk of prostate cancer or potentiate any undiagnosed prostate cancer.What can I do?Exercise has been shown to improve erectile dysfunction. Overall, exercise also modulates the body’s distribution of fat, even in the absence of weight loss. Long term endurance exercise has been shown to reduce SHBG and thus increase testosterone.Are there any other ways to increase testosterone?Yes. Off label, clomiphene can be used. Clomiphene is a drug that is usually used to help females with fertility issues. For some background of how clomiphene works, the regulation of testosterone is described further below.The brain (pituitary) produces the hormone Luteinising Hormone (LH). LH then stimulates the testes to produce testosterone. Testosterone inhibits the brain from producing more LH. Hence an equilibrium between LH and testosterone is reached in most men.Clomiphene has a similar structure to testosterone. It competes with testosterone in signalling to the brain to stop producing more LH. Hence in the presence of clomiphene, more LH is produced. This in turn increases the testosterone levels indirectly.This competition is not absolute but relative. The equilibrium still exists but is now shifted in favour of more testosterone and more LH. However should the levels increase too much, the brain will still be able to halt the production of LH and testosterone.This is different from testosterone. When testosterone is given directly, this is beyond any feedback mechanism. The brain is unable to regulate the levels of testosterone.