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Dr. Mariano – wonderful to see you on the boards again, I am always amazed at how you find the time to write such detailed responses. Wonder if you could help me….
I am a 39yo male who has suffered from sexual dysfunction (low libido, ED) since since my mid-twenties. That was the first symptom – after that fatigue crept in, then insomnia, some lower back pain, then horrible anxiety, etc. Until I hit rock bottom about 2 years ago.
After a series of learnings from the Forums and taking a battery of tests – I was put on T Cyp., HC, Armour, Vitamin D3, HCG, DHEA, Pregnenolone.
Anxiety is much, much better as is energy and sleep quality. But the sexual issues haven’t gone away. Slightly better, but not where it should be.
All tests look good, so for arguments sake – let’s assume T, E2, Thyroid, Adrenals are where they should be. I still feel “ramped” up from time to time and have wondered about Nervous System issues.
Going with the previous assumptions – where would you begin to look next?
@wondering 293 wrote:
Dr. Mariano – wonderful to see you on the boards again, I am always amazed at how you find the time to write such detailed responses. Wonder if you could help me….
I am a 39yo male who has suffered from sexual dysfunction (low libido, ED) since since my mid-twenties. That was the first symptom – after that fatigue crept in, then insomnia, some lower back pain, then horrible anxiety, etc. Until I hit rock bottom about 2 years ago.
After a series of learnings from the Forums and taking a battery of tests – I was put on T Cyp., HC, Armour, Vitamin D3, HCG, DHEA, Pregnenolone.
Anxiety is much, much better as is energy and sleep quality. But the sexual issues haven’t gone away. Slightly better, but not where it should be.
All tests look good, so for arguments sake – let’s assume T, E2, Thyroid, Adrenals are where they should be. I still feel “ramped” up from time to time and have wondered about Nervous System issues.
Going with the previous assumptions – where would you begin to look next?
Welcome!
It is not so much I’m on the boards again as much as this is my own board. I still write in the other forum. But the questions posed haven’t been so interesting lately. I also wanted to be on a board with a much broader outlook on health and mental health issues. I have also been interested in having a forum where women can also participate.
OK. Let’s assume reproductive hormone, thyroid and adrenal issues are addressed – and that is a huge assumption. I’d want to see the numbers myself since I read for behavioral issues as opposed to primarily physical health issues – thus the tolerances are much tighter for what I do. One doctor’s optimal may not be my own idea of optimal.
There are many other areas to address.
For example, in the endocrine system, in regard to libido, growth hormone should be assessed. Blood sugar control – insulin resistance needs assessment.
Nutritional status needs to be addressed. Are there optimized fat soluble vitamins (e.g. A, B12, D). Is there adequate protein intake to make neurotransmitters. Are there adequate B-vitamins including folate, B6. Are there adequate minerals – e.g. iron, magnesium, zinc, etc. One has to have a high density nutritious diet – not just taking everything in supplements. This would help fill in all the other necessary nutrients. Nutrition is a huge area where dysfunction occurs. I like old fashion diets, not the modern foods people eat. If a person has cavities or needed braces, they haven’t had enough nutrition.
The nervous system side should be assessed. Feeling “ramped up” may mean there is still excessive norepinephrine production, which then causes a loss of dopamine production. Dopamine signaling is central to libido.
Having energy yet feeling “ramped up” would make me suspicious that energy production is still impaired. Sympathetic nervous system overactivity is an adaptive response to impaired energy production either from a signaling stance (e.g. thyroid, adrenals) or a metabolic stance (e.g. nutritional deficiency).
etc.
Thank you for the response Dr. M. I think the info I have received from you and Dr. Crisler have pretty much saved my life or at least given me a normal life.
If I trace my symptoms back to when they started, it was about 6 months after taking a new job which was a highly stressful position with a psychotic boss. I have always wondered if stress (norepinephrine ?) was a key issue – fyi.. I do have family history of Hypothyroidism, etc.
So while my recent “rock bottom” state is long gone, I still feel like I did when I first started feeling poorly.
Given your above response, I would like to go see my Dr. with some good questions. Would you consider…
1. A1C test for insulin resistance?
2. I am on Armour and my Dr. only tests TSH, Free T4 and Total T3.
3. Have you had success using Effexor (or other) to reduce anxiety and get libido, erectile function back?IMPORTANT CLUE ?
If I go back to my physical peak- say 18. I could orgasm a couple times a day, but had a refractory period. But I had a definite strong libido and strong erections. Now I can orgasm almost at will, but low libido and ED. Seems like high norepinephrine. Not sure what to do/ask next.Thank you again.
@wondering 317 wrote:
Thank you for the response Dr. M. I think the info I have received from you and Dr. Crisler have pretty much saved my life or at least given me a normal life.
If I trace my symptoms back to when they started, it was about 6 months after taking a new job which was a highly stressful position with a psychotic boss. I have always wondered if stress (norepinephrine ?) was a key issue – fyi.. I do have family history of Hypothyroidism, etc.
So while my recent “rock bottom” state is long gone, I still feel like I did when I first started feeling poorly.
Given your above response, I would like to go see my Dr. with some good questions. Would you consider…
1. A1C test for insulin resistance?
2. I am on Armour and my Dr. only tests TSH, Free T4 and Total T3.
3. Have you had success using Effexor (or other) to reduce anxiety and get libido, erectile function back?IMPORTANT CLUE ?
If I go back to my physical peak- say 18. I could orgasm a couple times a day, but had a refractory period. But I had a definite strong libido and strong erections. Now I can orgasm almost at will, but low libido and ED. Seems like high norepinephrine. Not sure what to do/ask next.Thank you again.
INSULIN RESISTANCE:
Insulin resistance is present if:
1. Fasting glucose > 100
2. Fasting insulin > 10 or
3. Triglyceride to HDL Cholesterol ratio (in American units) > 3.5 or
4. 3-Hour glucose tolerance test shows any hourly glucose after 75 oral glucose load > 150.Hemoglobin A1c is a very poor test for insulin resistance. It just isn’t sensitive enough.
THYROID TESTING:
My basic thyroid panel would be: Total T4, Free T3. TSH would be optional.
My fuller follow up thyroid panel would be: Total T4, Free T3, Total T3, Free T4, TSH.
Total T4 is highly important. It gives me an idea of how much thyroid hormone may be needed for a replacement dose. This is true particularly when using Levothyroxine. I generally do not want dosing to go past 12 (14 if on birth control). Also, generally, if T4 > 8, and a person is exhibiting hypothyroid symptoms, then the problem is not production of thyroid hormone. The problem is in either converting thyroid to T3 and producing thyroid binding proteins to allow sufficient Free T3 or the problem is in cellular metabolism (e.g. low iron or other nutrients) which prevent thyroid from triggering the cellular metabolic changes associated with thyroid hormone (e.g. increased number and size of mitochondria with increased citric acid cycle capacity to produce ATP). Generally, if T4 is OK, I go after those other problems rather than just adding more thyroid hormone. I may not even need to add thyroid hormone alone if these other issues are addressed first.
EFFEXOR:
Effexor primarily acts to increase serotonin signal duration from 1 to 150 mg a day. From 150 tp 225 mg a day, it then also prolongs norepinephrine signal duration. Then past 225 mg a day, it mildly prolongs dopamine signal duration. Given these characteristics, I would not expect Effexor to improve libido and erectile dysfunction. Rather, I would expect it to lower libido and erectile dysfunction in general. This exception would be a person who has significantly high norepinephrine signaling, which contributes to a loss of libido and anxiety. Increasing serotonin signaling may just reduce norepinephrine enough that that person may be able to relax, have restoration of dopamine signaling and then improved libido. I usually expect this to be rare since increasing serotonin itself reduces dopamine signaling, thus lowering libido. It may be worth a trial at least to see if it would work. Since it increases norepinephrine, it doesn’t blunt libido as much as a pure serotonin reuptake inhibitor.
Is there anything to help reduce norepinephrmne directly to reduce that stressed out feeling that also doesnt kill libido. I am considering counselign as well to help. I think I understand my stressors, but wonder if vocalizing them would help – in your experience, does just getting it off your chest give meaningful responses.
@DrMariano 329 wrote:
INSULIN RESISTANCE:
Insulin resistance is present if:
1. Fasting glucose > 100
2. Fasting insulin > 10 or
3. Triglyceride to HDL Cholesterol ratio (in American units) > 3.5 or
4. 3-Hour glucose tolerance test shows any hourly glucose after 75 oral glucose load > 150.Hemoglobin A1c is a very poor test for insulin resistance. It just isn’t sensitive enough.
THYROID TESTING:
My basic thyroid panel would be: Total T4, Free T3. TSH would be optional.
My fuller follow up thyroid panel would be: Total T4, Free T3, Total T3, Free T4, TSH.
Total T4 is highly important. It gives me an idea of how much thyroid hormone may be needed for a replacement dose. This is true particularly when using Levothyroxine. I generally do not want dosing to go past 12 (14 if on birth control). Also, generally, if T4 > 8, and a person is exhibiting hypothyroid symptoms, then the problem is not production of thyroid hormone. The problem is in either converting thyroid to T3 and producing thyroid binding proteins to allow sufficient Free T3 or the problem is in cellular metabolism (e.g. low iron or other nutrients) which prevent thyroid from triggering the cellular metabolic changes associated with thyroid hormone (e.g. increased number and size of mitochondria with increased citric acid cycle capacity to produce ATP). Generally, if T4 is OK, I go after those other problems rather than just adding more thyroid hormone. I may not even need to add thyroid hormone alone if these other issues are addressed first.
EFFEXOR:
Effexor primarily acts to increase serotonin signal duration from 1 to 150 mg a day. From 150 tp 225 mg a day, it then also prolongs norepinephrine signal duration. Then past 225 mg a day, it mildly prolongs dopamine signal duration. Given these characteristics, I would not expect Effexor to improve libido and erectile dysfunction. Rather, I would expect it to lower libido and erectile dysfunction in general. This exception would be a person who has significantly high norepinephrine signaling, which contributes to a loss of libido and anxiety. Increasing serotonin signaling may just reduce norepinephrine enough that that person may be able to relax, have restoration of dopamine signaling and then improved libido. I usually expect this to be rare since increasing serotonin itself reduces dopamine signaling, thus lowering libido. It may be worth a trial at least to see if it would work. Since it increases norepinephrine, it doesn’t blunt libido as much as a pure serotonin reuptake inhibitor.
Is there anything to help reduce norepinephrine directly to reduce that stressed out feeling that also doesnt kill libido. I am considering counselign as well to help. I think I understand my stressors, but wonder if vocalizing them would help – in your experience, does just getting it off your chest give meaningful responses.
My “edginess” often makes it difficult to stay focused for a length of time, which bothers me at work.
@wondering 332 wrote:
Is there anything to help reduce norepinephrmne directly to reduce that stressed out feeling that also doesnt kill libido. I am considering counselign as well to help. I think I understand my stressors, but wonder if vocalizing them would help – in your experience, does just getting it off your chest give meaningful responses.
@wondering 332 wrote:
Is there anything to help reduce norepinephrmne directly to reduce that stressed out feeling that also doesnt kill libido. I am considering counselign as well to help. I think I understand my stressors, but wonder if vocalizing them would help – in your experience, does just getting it off your chest give meaningful responses.
@wondering 333 wrote:
Is there anything to help reduce norepinephrine directly to reduce that stressed out feeling that also doesnt kill libido. I am considering counselign as well to help. I think I understand my stressors, but wonder if vocalizing them would help – in your experience, does just getting it off your chest give meaningful responses.
My “edginess” often makes it difficult to stay focused for a length of time, which bothers me at work.
PSYCHOTHERAPY:
Psychotherapy is an excellent intervention to help reduce stress. Important goals are to help remodel a person’s belief system – their internal model of reality – to one more aligned with reality. This improves mindfulness. Therapy also helps improve one’s behavioral skills to improve distress tolerance, self-nurturing, problem solving, etc. Vocalizing one’s problems also helps one separate and encapsulate one’s problems, which helps reduce the stress and distraction they may cause on here-and-now activities.
In the treatment of bipolar disorder, for example, psychotherapy improves the condition by about 30%. This is actually as good as or even better than any FDA approved treatment of bipolar disorder. Medications for bipolar disorder improve the condition by about 10-30%. Combining both modalities would then be the best treatment. Note that this combination would be about a 50% improvement in a person’s condition. This is where additional work needs to be done – such as addressing as full of the actual pathophysiology of the illness. Medications only address a small part of the pathophysiology of the illness.
OTHER BEHAVIORAL INTERVENTIONS:
Other behavioral interventions can also reduce stress significantly. They include practicing meditation, yoga, Tai Chi, etc.
OTHER MEDICAL TREATMENTS TO REDUCE NOREPINEPHRINE:
Serotonin is the one signal, which if increased directly in treatment to control stress (norepinephrine), reliably reduces libido and sexual function – particularly in women (who often become anorgasmic with Serotonin Reuptake Inhibitors).
Improving the function of the other control signals on norepinephrine would make it less likely to have reduced libido. For example, optimizing the following helps reduce stress:
– Dopamine
– GABA
– Thyroid hormone
– Cortisol
– DHEA
– Progesterone
– Testosterone
– Insulin – particularly reduction of excess
– Estrogen – improvement in deficit or reduction in excess.
– Growth Hormone
– Vitamin D
– Vitamin A
– etc. etc.NUTRITIONAL INTERVENTIONS:
For any of the signals (such as thyroid hormone), the appropriate cofactors must be in place so that the metabolic changes triggered by the signal can occur.
Thyroid signaling, for example, requires adequate amounts of the B-vitamins, selenium, iron, tyrosine, iodine, vitamin A,, etc. to work.
Nutrients themselves may be used medicinally.
For example, tryptophan or 5-hydroxytryptophan may be used to raise serotonin signaling to reduce norepinephrine signaling. This may allow the body to improve serotonin production and improve serotonin signaling while minimizing the effects on dopamine signaling which reduces libido.
Adding SAMe may help improve neurotransmitter production and improve estrogen metabolism to reduce excess stress-inducing estrogen, for example.
Adding adequate amounts of omega-3 fatty acids (withi EPA and DHA being the most active and important) is important to maintaining mood stability. The omega-3 fatty acids have mood stabilizing properties – with many mechanisms of action similar to Lithium and Depakote. The omega-3 fatty acids are also anti-inflammatory. They would help reduce the pro-inflammatory signals from the immune system and brain which increase stress.
Etc. Etc. Nutrition is a huge huge data set.
I will consider psychotherapy.
Whether my levels are optimized in your view or not, I don’t know. But I currently take…
Testosterone
Hydrocortisone
Armour
HCG
Pregnenolone
DHEA
occasional Iodoral
multivitamin
5000 ius of Vitamin D3
Fish oilWhats a suffcient amount of Fish oil – I take 500mg EPA and 500mg DHA for 1g total.
@DrMariano 336 wrote:
PSYCHOTHERAPY:
Psychotherapy is an excellent intervention to help reduce stress. Important goals are to help remodel a person’s belief system – their internal model of reality – to one more aligned with reality. This improves mindfulness. Therapy also helps improve one’s behavioral skills to improve distress tolerance, self-nurturing, problem solving, etc. Vocalizing one’s problems also helps one separate and encapsulate one’s problems, which helps reduce the stress and distraction they may cause on here-and-now activities.
In the treatment of bipolar disorder, for example, psychotherapy improves the condition by about 30%. This is actually as good as or even better than any FDA approved treatment of bipolar disorder. Medications for bipolar disorder improve the condition by about 10-30%. Combining both modalities would then be the best treatment. Note that this combination would be about a 50% improvement in a person’s condition. This is where additional work needs to be done – such as addressing as full of the actual pathophysiology of the illness. Medications only address a small part of the pathophysiology of the illness.
OTHER BEHAVIORAL INTERVENTIONS:
Other behavioral interventions can also reduce stress significantly. They include practicing meditation, yoga, Tai Chi, etc.
OTHER MEDICAL TREATMENTS TO REDUCE NOREPINEPHRINE:
Serotonin is the one signal, which if increased directly in treatment to control stress (norepinephrine), reliably reduces libido and sexual function – particularly in women (who often become anorgasmic with Serotonin Reuptake Inhibitors).
Improving the function of the other control signals on norepinephrine would make it less likely to have reduced libido. For example, optimizing the following helps reduce stress:
– Dopamine
– GABA
– Thyroid hormone
– Cortisol
– DHEA
– Progesterone
– Testosterone
– Insulin – particularly reduction of excess
– Estrogen – improvement in deficit or reduction in excess.
– Growth Hormone
– Vitamin D
– Vitamin A
– etc. etc.NUTRITIONAL INTERVENTIONS:
For any of the signals (such as thyroid hormone), the appropriate cofactors must be in place so that the metabolic changes triggered by the signal can occur.
Thyroid signaling, for example, requires adequate amounts of the B-vitamins, selenium, iron, tyrosine, iodine, vitamin A,, etc. to work.
Nutrients themselves may be used medicinally.
For example, tryptophan or 5-hydroxytryptophan may be used to raise serotonin signaling to reduce norepinephrine signaling. This may allow the body to improve serotonin production and improve serotonin signaling while minimizing the effects on dopamine signaling which reduces libido.
Adding SAMe may help improve neurotransmitter production and improve estrogen metabolism to reduce excess stress-inducing estrogen, for example.
Adding adequate amounts of omega-3 fatty acids (withi EPA and DHA being the most active and important) is important to maintaining mood stability. The omega-3 fatty acids have mood stabilizing properties – with many mechanisms of action similar to Lithium and Depakote. The omega-3 fatty acids are also anti-inflammatory. They would help reduce the pro-inflammatory signals from the immune system and brain which increase stress.
Etc. Etc. Nutrition is a huge huge data set.
@wondering 337 wrote:
Whats a suffcient amount of Fish oil – I take 500mg EPA and 500mg DHA for 1g total.
See my answer in a separate post:
Dr Mariano, what do you mean by this:
“If a person […] needed braces, they haven’t had enough nutrition.”
@compaq 6697 wrote:
Dr Mariano, what do you mean by this:
“If a person […] needed braces, they haven’t had enough nutrition.”
Weston Price, a dentist in the 1930s, studied the relationship between nutrition and health in various cultural groups around the world. He wrote about his studies in his book, Nutrition and Physical Degeneration. You can start learning about his findings at http://www.westonaprice.org, a site founded by Sally Fallon and Mary Enig, who wrote the book, Nourishing Traditions, based on Weston Price’s findings. This is the book I would use as a starting point for nutrition.
One important finding of Weston Price is that people who have high-nutrient density diets have wider jaws and rounder faces which gave teeth enough space to grow in straight. High-nutrient density diets generally are the traditional diet of each culture. This is in contrast to modern diets which do not have nutrient density. (Additionally, high-nutrient density diets protected people from cavities, even in cultures where the people don’t brush their teeth, and the people were much healthier compared to those who ate modern less-nutrient dense diets.)
When children do not have high nutrient density diets – or if they are picky eaters resulting in reduction in nutrient density of the foods they eat – then their faces end up being thinner with jaws which do not have enough space to have straight teeth. These children then need braces.
In recent studies regarding nutrient density and obesity and diabetes, people who had low nutrient dense diets (poor people) had a 600 percent greater risk of developing obesity and diabetes. This mirrors what Weston Price found in the 1930s.
High nutrient density diets optimize metabolism, health, and mental function.
would never imagine that so very intresting , this makes alot of sense since someone who has better nutrition will get a stronger growth hormone kick during puberty is this what its based on ?
@akiravp82 6702 wrote:
would never imagine that so very intresting , this makes alot of sense since someone who has better nutrition will get a stronger growth hormone kick during puberty is this what its based on ?
Overall metabolism and cellular signaling is better with high density nutrition.
It is not so much I’m on the boards again as much as this is my own board. I still write in the other forum.
Dr. M or anyone, what is the “other” board that you post at?
@j-man1 6705 wrote:
Dr. M or anyone, what is the “other” board that you post at?
I haven’t posted on other boards in years on topics related to this forum.
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