Guest guest Posted November 8, 2007 Report Share Posted November 8, 2007 Hi everyone, I have a 47 year old male patient who has a chief complaint of low testosterone, along with high stress, poor digestion, and decreasing libido. My main dilemma is whether to use herbs which have been shown to increase testosterone – (testosterone often being a reflection of KD yang in both CM terms and pharmaceutical research), even though he doesn't present with much KD deficiency. Details of the case are below. His testosterone levels were 500 ng/dl in 6/07, 200 in 8/07 and 100 in 10/07. His stress is somewhat related to his work but mostly his marriage, as his wife is finding herself and trying to decide whether she wants to be married anymore; they have 2 children. He says feels that stress could be the root of all his physical problems. He is in both individual and marriage counseling. Despite the risks, he wants testosterone supplementmentation but his therapist convinced him to try Chinese medicine fist. He feels increasingly fatigued and depressed, and states that he would rather live 10 more good years feeling good through testosterone supplementation than 30 years the way he feels now. His digestive symptoms are a feeling of fullness and bloating after he eats ( " food just sits there " ) for 1 year, regardless of what he eats, and 2 or more loose bowel movements throughout the day. He states that his appetite is still good, and he is trying to eat smaller, more frequent meals, but it hasn't seemed to help. He has always previously had strong digestion. His libido decline concerns him, as he has always defined himself to some degree through sex. He acknowledges that the decline may be due in part to his wife's rejection of him for the past 6 months, as well as the declining testosterone. Otherwise, he rates his overall energy at 7/10 (down from his previous 10/10). He has a stocky muscular build and runs daily for exercise, and gets increasingly irritable and anxious if he doesn't exercise. He feels hot overall, but has noticed his feet occasionally getting cold lately. He is thirsty for cold water and doesn't drink much caffeine, although when he does, it occasionally gives him a temporal headache. He sleeps well, occasionally waking briefly around 4 am. He urinates 6-8 x/ day (neither particularly scanty nor profuse amounts), and doesn't get up at night to pee. He has had 2-3 concussions and some previous musculoskeletal complaints (post-accident hip pain). He has gained a little weight since his testosterone has been declining. His tongue is red/ dusky with a red tip, and a thick, slightly dry and slightly turbid white coat, and distended purple sublingual veins. His pulse is wiry, slightly slippery and moderately slow. I have only seen him once, and am first addressing his digestion, working on a diagnosis of Liver overacting on Spleen, leading to food stagnation and dampness. I gave him a modified bulk chai hu shu gan wan (chai hu 6, bai shao 9, zhi ke 9, zhi gan cao 6, shan zha 6, ji nei jin 6, yu jin 6, chen pi 6, xiang fu 6, bai zhu 9, pei lan 6) over 2 days, and patent bao he wan to use as needed. Ultimately he wants his testosterone levels to go back up. Clearly there is some SP xu here, and possibly an argument for some KD yang xu as well, but I hesitate to give him a bunch of hot herbs (yin yang huo, ba ji tian, etc.) just to boost his testosterone. Please forgive the long post. I am a new practitioner, and any advice/ experience would be appreciated. Thanks, Kate Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 9, 2007 Report Share Posted November 9, 2007 (Kate Wrote) Hi everyone, I have a 47 year old male patient who has a chief complaint of low testosterone, along with high stress, poor digestion, and decreasing libido. My main dilemma is whether to use herbs which have been shown to increase testosterone – (testosterone often being a reflection of KD yang in both CM terms and pharmaceutical research), even though he doesn't present with much KD deficiency. Details of the case are below. His testosterone levels were 500 ng/dl in 6/07, 200 in 8/07 and 100 in 10/07. His stress is somewhat related to his work but mostly his marriage, as his wife is finding herself and trying to decide whether she wants to be married anymore; they have 2 children. He says feels that stress could be the root of all his physical problems. He is in both individual and marriage counseling. Despite the risks, he wants testosterone supplementmentation but his therapist convinced him to try Chinese medicine fist. He feels increasingly fatigued and depressed, and states that he would rather live 10 more good years feeling good through testosterone supplementation than 30 years the way he feels now. His digestive symptoms are a feeling of fullness and bloating after he eats ( " food just sits there " ) for 1 year, regardless of what he eats, and 2 or more loose bowel movements throughout the day. He states that his appetite is still good, and he is trying to eat smaller, more frequent meals, but it hasn't seemed to help. He has always previously had strong digestion. His libido decline concerns him, as he has always defined himself to some degree through sex. He acknowledges that the decline may be due in part to his wife's rejection of him for the past 6 months, as well as the declining testosterone. Otherwise, he rates his overall energy at 7/10 (down from his previous 10/10). He has a stocky muscular build and runs daily for exercise, and gets increasingly irritable and anxious if he doesn't exercise. He feels hot overall, but has noticed his feet occasionally getting cold lately. He is thirsty for cold water and doesn't drink much caffeine, although when he does, it occasionally gives him a temporal headache. He sleeps well, occasionally waking briefly around 4 am. He urinates 6-8 x/ day (neither particularly scanty nor profuse amounts), and doesn't get up at night to pee. He has had 2-3 concussions and some previous musculoskeletal complaints (post-accident hip pain). He has gained a little weight since his testosterone has been declining. His tongue is red/ dusky with a red tip, and a thick, slightly dry and slightly turbid white coat, and distended purple sublingual veins. His pulse is wiry, slightly slippery and moderately slow. I have only seen him once, and am first addressing his digestion, working on a diagnosis of Liver overacting on Spleen, leading to food stagnation and dampness. I gave him a modified bulk chai hu shu gan wan (chai hu 6, bai shao 9, zhi ke 9, zhi gan cao 6, shan zha 6, ji nei jin 6, yu jin 6, chen pi 6, xiang fu 6, bai zhu 9, pei lan 6) over 2 days, and patent bao he wan to use as needed. Ultimately he wants his testosterone levels to go back up. Clearly there is some SP xu here, and possibly an argument for some KD yang xu as well, but I hesitate to give him a bunch of hot herbs (yin yang huo, ba ji tian, etc.) just to boost his testosterone. Please forgive the long post. I am a new practitioner, and any advice/ experience would be appreciated. Thanks, Kate (Sharon Wrote) Hi Kate, This is a good question. It's so easy to think kidney in a case like this. It takes a certain Chinese medical discipline to look at what is actually going on with a real person and avoid treating a western diagnosis in a knee jerk manner. Your intake is very complete. I've treated a lot of low libido in both men and women as well as impotence. I would not treat kidney in a case like this at all. He has no kidney signs or symptoms. Most of the cases I see are like this and I have had testosterone levels balance out without using any Kidney Yang tonics. This does sound stress related but that does not mean Chinese medicine could not treat it. It is still stress inducing a reaction in his body. The herbs and acupuncture can help his body not take on the stress in such a strong way. I think your formula is okay but I would have a couple of suggestions. Rather than treat food stasis, I would want to help down-bear his Qi mechanism by using Ban Xia Xie Xin Tang. This is better when there is a red tongue with a thick coat. Down-bearing the upper digestion this way will help with opening him up and helping his Qi flow more easily in the lower warmer. Activating the upper digestion will also help him transform his food and fluids and stop the diarrhea. You won't have to address this separately. In addition to opening his Liver Qi as you are doing, I would also take into account the depressive heat (red tongue)and the blood stasis (dusky tongue). I do not see any Spleen Qi deficiency. His loose stool can be explained by the Liver invading the Large intestine. His fatigue simply means that his full energy is not available to him which is often the case with depressed Qi. And again - there is no Kidney indication. Using Kidney Yang/ Jing tonics could be quite bad for him with his depressive heat issues. Let us know how this works out.... best Sharon Sharon Weizenbaum 86 Henry Street Amherst, MA 01002 413-549-4021 sweiz www.whitepinehealingarts.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 9, 2007 Report Share Posted November 9, 2007 Kate - Sometimes it helps me to understand the physiology or these types of situations from both the TCM and the western point of view. Although there are not always direct correlations, the western physiology (of say testosterone production and metabolism) can sometimes be useful guideposts in our treatment process. A research article in the American Journal of Physiological Regulatory Integrative Comparative Physiology ( http://ajpregu.physiology.org/cgi/content/full/273/4/R1407#BIBL) discusses how age alters the feed-forward and feed-back linkages between pituitary LH and Testosterone production in healthy men. The gist of the article is that the hypothalamic/pituitary/gonadal feedback loop becomes less stable as men age, and hence testosterone production and metabolism is effected. Part of the mechanism may be related to LH-resistance at the level of the Leydig cells, and they also postulated that the problem may be partially related to inadequate function of sex-hormone-binding-globulins (shbg). Interestingly, this scenario is not uncommon with what occurs in age- related ovarian resistance to pituitary FSH (diminished ovarian reserve), or age-related insulin resistance/type 2 diabetes. Of course the essential question for us as TCM practitioners is, how does this related to TCM pathophysiology, diagnosis and treatment? I think that one of your most recent posts asked the question can liver/spleen disharmony lead to low testosterone or be involved somehow in this laboratory finding. Sharon (and I think Al) rightly pointed out that the case below shows very little in terms of actual kidney yang deficiency from a pattern-disharmony point of view. There is however LV/SP/Large Intestine disharmony aka Qi Mechanism imbalance (see Will Maclean & Jane Lyttleton's " Handbook of Internal Medicine " Volume #2 on the Spleen and Stomach for an excellent discussion of the Qi Mechanism). Also, Sharon's recommendation to use Ban Xia Xie Xin Tang is an elegant choice. It is an often overlooked " harmonizing " formula, and it is definitely clinically expedient to clear any excess before addressing any deficiencies (i.e. Kidney Yang Xu). So how do we reconcile Sharon's clinical experience of having testosterone levels " balance out " or normalize by treating a patient's stress or qi stagnation, with the western physiology of testosterone production and metabolism? Well, we know that stress and bodily imbalance (i.e. poor diet, lack of exercise, environmental toxins) can H-P-O and H-P-A axis by leading to insensitivity to pituitary hormones at the level of the ovary or testicle. We also know that downstream metabolism of hormones is partially carried out by the physiological Liver. So, anything that helps the functional Chinese Liver work more efficiently, should help both the nervous/endocrine system (HPA axis) work better, and help the physiological liver work better. This in turn should help both the feed-forward, and feed-back systems involved in Testosterone production and metabolism function more optimally. Also, the penis is said to be the " great ancestral tendon of the Liver " , and because the liver channel goes to the genitalia, and Qi is the commander of blood, it would follow that any treatment principle that rectifies the Qi mechanism - i.e allows for more free coursing of liver qi - should also allow for more free flowing of liver blood to where it needs to go: the great ancestral tendon, and of course to the testicles bearing LH to the Leydig cells. Just musing, Ray Rubio On Nov 9, 2007, at 8:16 AM, sharon weizenbaum wrote: > (Kate Wrote) > > Hi everyone, > > I have a 47 year old male patient who has a chief complaint of low > testosterone, along with high stress, poor digestion, and decreasing > libido. My main dilemma is whether to use herbs which have been shown > to increase testosterone & #65533;(testosterone often being a reflection of > KD yang in both CM terms and pharmaceutical research), even though he > doesn't present with much KD deficiency. > > Details of the case are below. > > His testosterone levels were 500 ng/dl in 6/07, 200 in 8/07 and 100 in > 10/07. > > His stress is somewhat related to his work but mostly his marriage, as > his wife is finding herself and trying to decide whether she wants to > be married anymore; they have 2 children. He says feels that stress > could be the root of all his physical problems. He is in both > individual and marriage counseling. Despite the risks, he wants > testosterone supplementmentation but his therapist convinced him to > try Chinese medicine fist. He feels increasingly fatigued and > depressed, and states that he would rather live 10 more good years > feeling good through testosterone supplementation than 30 years the > way he feels now. > > His digestive symptoms are a feeling of fullness and bloating after he > eats ( " food just sits there " ) for 1 year, regardless of what he eats, > and 2 or more loose bowel movements throughout the day. He states that > his appetite is still good, and he is trying to eat smaller, more > frequent meals, but it hasn't seemed to help. He has always previously > had strong digestion. > > His libido decline concerns him, as he has always defined himself to > some degree through sex. He acknowledges that the decline may be due > in part to his wife's rejection of him for the past 6 months, as well > as the declining testosterone. > > Otherwise, he rates his overall energy at 7/10 (down from his previous > 10/10). He has a stocky muscular build and runs daily for exercise, > and gets increasingly irritable and anxious if he doesn't exercise. He > feels hot overall, but has noticed his feet occasionally getting cold > lately. He is thirsty for cold water and doesn't drink much caffeine, > although when he does, it occasionally gives him a temporal headache. > He sleeps well, occasionally waking briefly around 4 am. He urinates > 6-8 x/ day (neither particularly scanty nor profuse amounts), and > doesn't get up at night to pee. He has had 2-3 concussions and some > previous musculoskeletal complaints (post-accident hip pain). He has > gained a little weight since his testosterone has been declining. > > His tongue is red/ dusky with a red tip, and a thick, slightly dry and > slightly turbid white coat, and distended purple sublingual veins. His > pulse is wiry, slightly slippery and moderately slow. > > I have only seen him once, and am first addressing his digestion, > working on a diagnosis of Liver overacting on Spleen, leading to food > stagnation and dampness. I gave him a modified bulk chai hu shu gan > wan (chai hu 6, bai shao 9, zhi ke 9, zhi gan cao 6, shan zha 6, ji > nei jin 6, yu jin 6, chen pi 6, xiang fu 6, bai zhu 9, pei lan 6) over > 2 days, and patent bao he wan to use as needed. > > Ultimately he wants his testosterone levels to go back up. Clearly > there is some SP xu here, and possibly an argument for some KD yang xu > as well, but I hesitate to give him a bunch of hot herbs (yin yang > huo, ba ji tian, etc.) just to boost his testosterone. > > Please forgive the long post. I am a new practitioner, and any advice/ > experience would be appreciated. > > Thanks, > Kate > > (Sharon Wrote) > > Hi Kate, > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.