Tongkat Ali, Clomid, and Secondary Hypogonadism
Tongkat Ali ( Eurycoma longifolia) has long been one of my favorite androgenic herbs for reversing hypogonadism. The action of Eurycoma longifolia is unique in the body for the way in which it activates the hypothalamus – pituitary – gonadal axis. This makes Tongkat Ali a standout herb for restarting a sluggish male reproductive system. But before we delve deeper into Tongkat Ali, lets first talk about the difference between primary hypogonadism (PH) and secondary hypogonadism (SH) and why SH is so prevalent today.
Primary hypogonadism (PH) is when the cells that are responsible for manufacturing testosterone in the testes (leydig cells) become damaged. For the most part, PH is rare and is confined to cases of serious illness and in anabolic androgenic steroid abuse, as seen in body builders. To achieve healthy, high levels of testosterone in cases of PH, the only real option is long term testosterone replacement therapy (TRT). But even in some cases of PH, the testes will repair themselves given time and the right circumstances. PH is rare outside of the body building community and most people with low levels of testosterone do not have it.
Secondary hypogonadism (SH) is what most people are experiencing when they are experiencing low levels of testosterone. This is an error in the hypothalamus – pituitary – gonadal axis, the communication line for signaling the testes to produce testosterone. Here, the hypothalamus (which is deep inside the brain) releases a hormone called gonadotropin releasing hormone (GnRH).
GnRH travels to the pituitary (again, inside the brain), where the presence of GnRH spurs the release of another hormone called luteinizing hormone [GnRH also causes the release of follicle stimulating hormone (FHS) which causes the nurse cells in the testes to mature sperm—the two are closely related]. Luteinizing hormone then travels in the general blood supply until it reaches the leydig cells in the testes and instigates the production of testosterone.
In secondary hypogonadism, the hypothalamus does not produce any or enough GnRH and as such, the leydig cells are not activated and testosterone is not produced (or it is under produced). Tumors on the pituitary gland often cause secondary hypogonadism (SH), and if SH is expected a pituitary tumor should be ruled out. But these tumors are extremely rare as compared to the wide prevalence of SH.
What causes most SH is some kind of illness. I know, this sounds very vague, and is because it is very vague. Many different illnesses, diseases, and even medications can cause SH, including after the illness or disease has been addressed. Long term, many illnesses seem to cause SH.
However, the disease approach to SH does not explain the wide prevalence of it as seen today. Unspecific to any acute disease, I have found that accumulated stress in life, combined with how we tend to live our lives, also causes secondary hypogonadism, and that this is the source of the rampant low levels of testosterone seen today. I see this so often that I have just started referring it to as “burnout.” We burn ourselves out, and this causes a state of exhaustion in the body similar to a serious disease, and the result is SH.
Secondary Hypogonadism and Tongkat Ali (Eurycoma longifolia)
Tongkat Ali works on the hypothalamus – pituitary – gonadal axis in the body and it does so on several fronts. Tongkat Ali is able to bind to sex hormone binding globulin (similar to Nettle Root) and raise the ratio of free to bound testosterone. Tongkat Ali is also able to stimulate the production of the prohormone DHEA, which in turn promotes an increase in testosterone. But what is most interesting is that upon administering suitable doses of Tongkat Ali, serum (blood) levels of follicle stimulating hormone and luteinizing hormone are both increased. This demonstrates how Tongkat Ali is working specifically on the systems which promote the testes to produce more testosterone.
Tongkat Ali is able to have so many functions in the body because it contains many classes of medicinal compounds, including alkaloids, quassinoids, quassinoid diterpenoids, eurycolactone, eurycomalactone, phenolic component, tannins and a bioactive peptide of 4.3 kDa. This peptide is responsible for the unique aphrodisiac properties of Tongkat Ali. Human research into Tongkat Ali has shown its ability to increase both levels of wellbeing and sexual performance in men.
In terms of male reproductive health, Tongkat Ali increases levels of free testosterone, increases levels of DHEA, decreases levels of SHBG, has a proven aphrodisiac/libido promoting effect, and has been shown to increase sexual performance. This is based on both human and animal research. In my opinion, the most promising effect that Tongkat Ali has on the body is its ability to stimulate the hypothalamic – pituitary – gonadal axis, raising levels of both follicle stimulating hormone (FSH) and luteinizing hormone (LH), reversing secondary hypogonadism (SH).
Secondary Hypogonadism and Clomid (Clomiphene Citrate)
Now it is time to briefly switch gears from medicinal herbs to pharmaceutical drugs. Clomiphene Citrate (brand name Clomid) is a synthetic drug that was developed in the 1960s as a fertility treatment for women. Clomid forces ovulation. Clomiphene Citrate binds to estrogen receptors on the hypothalamus. For men, when the estrogen receptors are stimulated on the hypothalamus, the body senses that estrogen levels are high and subsequently produces more testosterone (because the negative feedback mechanism of the endocrine system). Clomid is not estrogenic and has no other estrogenic effect on the body.
While Clomid was developed to treat infertility in women, it has been used for decades as an off label treatment for secondary hypogonadism in men. Clomiphene Citrate works on the same hypothalamus – pituitary – gonadal axis as Tongkat Ali does and Clomid is able, long term, to elevate testosterone levels into very high levels, especially in otherwise healthy men. Both drugs (one synthetic with several concerning side effect and one a plant with many beneficial “side effects”) seem to accomplish the same goal: increasing levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH), which then stimulates the testes to produce more testosterone. With Clomid, and aromatase blocker needs to be taken alongside it, but with Tongkat Ali, it acts also to block sex hormone binding globulin (SHBG) and thus blocks the aromatization of testosterone into estrogen.
What is most interesting with Clomid treatment are the long term effects. A treatment course of Clomid may only be several (2-3) months. The purpose of this is that Clomid has a stimulatory—a resetting—effect on the hypothalamus, so that after cessation of Clomid, testosterone levels remain high, and these results appear to be permanent. Unlike convention testosterone replacement therapy (ie Androgel), the use of Clomid actually promotes the health of the testes and increases male fertility—a biomarker of male reproductive health.
This is exactly what I have also observed with Tongkat Ali and a few other select androgenic herbs, that they can have a long term effect of resetting the hypothalamus (what I have colloquially called the “testosterone thermostat”).
The most common side effects of Clomid include migraine headaches, vision changes (which can be so bad as to interfere with driving), and rapid cycling emotional disturbances (there are others, but these seem the most prevalent). Alternately, Tongkat Ali ( Eurycoma longifolia) has a set of “side effects” as well, including antimalarial, antibacterial, antitumor, and antioxidant. Furthermore, Tongkat Ali can be used in the preventional and treatment of osteoporosis. While I am of course biased towards what I see as a safer, better treatment using Tongkat Ali, I also support the use of Clomid as a last resort.
While the use of Clomid (Clomiphene Citrate) is “off label” and not approved by the FDA for treatment of secondary hypogonadism in men, several prominent studies have been done showing its safety and efficacy in treating SH. However, successful treatment must resolve the underlying health concerns which caused the SH in the first place. As is common with medicinal herbs, the Band-Aid approach does not seem to work here with pharmaceutical drugs either. This is where adjusting lifestyle and the use of tonic herbs vastly excels over allopathic, conventional Western medicine. If what caused the “burnout” in the first place isn’t remedied, it will be very difficult to find relief from the secondary hypogonadism (the low testosterone) the burnout caused.
The Underlying Cause of Secondary Hypogonadism Needs to be Addressed
Addressing burnout is a Magnum opus in its own right, and beyond the scope of this post. But to this, I suggest a two part approach. Firstly, we need to understand what caused the illness. If a person is burnout (no specific illness), they need to understand at both the deep and practical level what caused the burnout. Secondly, we need to understand what it is trying to teach us. While I tend to be a more literally minded person, I believe on a fundamental level that illness needs to be understood both on a scientific/Western medical level but also needs to be seen as appearing in life to teach a lesson. And that lesson needs to be understood. In terms of burnout, many times that lesson can be as simple as connecting an unsustainable lifestyle with the effects of it—the burnout. With that knowledge, a person can move forward. Chinese medicine, in my opinion, offers the most holistic and comprehensive metric for understanding illness on a fundamental level and finding appropriate treatment of it.