Testosterone Comprehensive Study

Atlanta Andropause Hormone Treatment

Testosterone levels peak in most men during the early to mid-20s. Between the ages of 40 and 70, the hormone-producing cells begin to wear away, causing men to lose nearly 60 percent of peak levels. Key symptoms of testosterone deficiency include depression, fatigue, low sex drive, irritability, hair loss, thinning and wrinkling of the skin, weight gain and weakening of bone and muscle tissue. Eventually, hormone imbalances can set the stage for the development of more serious conditions like heart disease, osteoporosis, pre-diabetes and erectile dysfunction. While many popular medications such as Viagra are available to help sustain an erection, none of these drugs work effectively without adequate testosterone. Appropriate hormone treatment could eliminate the need for Viagra and enable the man to have normal sexual function.

The following questionnaire, the Androgen Deficiency in Aging Males (ADAM) questionnaire, was developed at St. Louis University Medical School to detect the symptoms related to decreased testosterone levels in men.

The questionnaire contains the following ten questions:

1. Do you have a decrease in libido (sex drive)?

2. Do you have a lack of energy?

3. Do you have a decrease in strength, endurance, or both?

4. Have you lost height?

5. Have you noticed a decreased enjoyment of life?

6. Are you sad, grumpy, or both?

7. Are your erections less strong?

8. Have you noted a recent deterioration in your ability to play sports?

9. Are you falling asleep after dinner?

10. Has there been a recent deterioration in your work performance?

Any man answering “yes” to question 1 or 7 or any three other questions has a high likelihood of having a low testosterone level and should see his physician to be evaluated. If testosterone is low on appropriate testing, most of these symptoms are reversed or improved with testosterone replacement. A personalized hormone replacement therapy has positive benefits that can improve your life.

Lower testosterone levels may begin as early as the 40’s and 50’s.  Many factors can cause a decrese in testosterone levels. Before starting long-term testosterone replacement, a man should be carefully evaluated for other causes of  low testosterone. Pituitary or brain tumors can result in low testosterone and the treatment for these conditions may be surgery or other drugs.

Prescription drugs may affect sexual function and reduce testosterone levels. Other less causes can include nutritional factors, insomnia, stress and other life-style issues. When these conditions are recognized and treated, testosterone may normalize without the need for testosterone treatment.

Borderline-low values for total serum testosterone should be further evaluated, particularly in elderly and obese men. Because hypogonadism may be the initial sign of a pituitary tumor or systemic disease, a thorough workup is essential, especially in younger men. Classic symptoms of androgen deficiency (and male hypogonadism) at any age include fatigue, loss of muscular strength, poor libido, hot flushes, and sexual dysfunction. A morning measurement of total serum testosterone level is the screening test of choice for male hypogonadism. Patients with moderately low (200-350 ng/dL [6.94-12.15 nmol/L]) total serum testosterone levels should have their free or bioavailable testosterone level determined. Currently available testosterone replacement systems include injections, patches, gels, and buccal mucosa lozenges.

Men with hypogonadal disorders have symptoms that are sometimes ignored by the physician. With a longer life span and with advances in the treatment of cardiovascular disease, some aging men have decreased testosterone level and consequently increased risk of  cardiovascular disease, osteoporosis, sexual dysfunction, fatigue, and mood disturbances. Some recent studies supported the view that an age-related decline in testicular function may occur with associated symptoms, and testosterone replacement treatment improved lean body mass, increased hematopoiesis, decreased low-density lipoprotein (LDL) levels in conjunction with a constant ratio of LDL to high-density lipoprotein (HDL), improved libido, and improved well-being in older men with low testosterone levels.

Generally, prostate size and prostate-specific antigen (PSA) levels do not change in comparison with otherwise normal men. Elder men with hypogonadism have significantly reduced mean growth hormone level. Patients with adult-onset growth hormone deficiency also have increased cardiovascular-related mortality . Testosterone treatment results in a significant increase in 24-hour mean serum growth hormone value . Perhaps testosterone has an important role in the control of growth hormone secretion in adulthood, and testosterone therapy may have a positive clinical influence.

Contraindications to Testosterone Therapy ,  and Gonadotropin Therapy

Men with prostate cancer, male breast cancer, or untreated prolactinoma.

Treatment with these medications can stimulate tumor growth in androgen-dependent neoplasms. Careful examination of the male breast and prostate is required initially and at follow-up visits. In addition to prostate examination, baseline and follow-up PSA levels should be determined in older men with increased risk for prostate cancer. Men with symptomatic prostatism should undergo evaluation and treatment for this problem before testosterone replacement therapy is considered.

Relative Contraindications to the Use of Testosterone

Sleep apnea and polycythemia, which may cause hyperviscosity.  Testosterone treatment will tend to reduce sperm counts and testicular size and should not be used in men currently seeking fertility. Testosterone therapy can be used in the male patient with hypogonadism who are not interested in fertility or not able to achieve fertility.

The following preparations of testosterone have been approved by the FDA for clinical use:
• Long-acting intramuscular preparations
• Short-acting intramuscular preparations
• Scrotal patches
• Transdermal patches
• Transdermal gel
• Orally administered agents (Orally administered testosterone is quickly metabolized by the liver and cannot achieve sufficient blood levels over time to be useful.)

Monitoring Issues and Side Effects of Testosterone Therapy

Periodic follow-up of patients receiving testosterone therapy is needed. During the first year of such therapy, the clinical response and the side effects should be monitored at 3- to 4-month intervals. For patients receiving testosterone injections, a serum testosterone level should be measured at the midpoint between injections to ensure that the value is near the middle of the normal range. Most patients using testosterone gel have constant blood levels of testosterone over 24 hours; thus, the time of measurement is usually not critical. The testosterone patch preparations usually yield peak serum testosterone values within 4 to 8 hours after application.

Examination of the prostate should be done routinely, along with a prostate-related symptom assessment every 6 to 12 months. PSA levels should be determined annually in older men receiving testosterone replacement therapy. High PSA levels should be further evaluated with a highly specific PSA assay, if available. If results are abnormal, a urologic consultation should be sought, and testosterone replacement therapy should be terminated. Men receiving testosterone replacement therapy and finasteride should be considered for further evaluation even with PSA values in the upper normal range. Testosterone treatment should not be administered to men with high PSA values or significantly increasing PSA levels.

Testosterone, and especially dihydrotestosterone, stimulates growth of the the prostate and seminal vesicles, but this growth did not exceed the volumes expected in normal men . No clear relationship has been established between testosterone replacement therapy and prostate cancer, although anecdotal reports have been published (62). Men in whom symptomatic prostatism develops should undergo assessment before testosterone replacement therapy is continued.

Gynecomastia may result from the aromatization of testosterone to estradiol and changes in SHBG levels. Surgical therapy may be considered for some patients. Men with a genetic susceptibility to alopecia may note worsening of this problem with testosterone therapy. Testosterone stimulates the bone marrow production of erythrocytes. The result is an increased hematocrit in some men, with the possibility of hyperviscosity side effects (63). The hematocrit should be determined every 6 months for the first 18 months and then yearly thereafter if it is stable and normal. Testosterone therapy should be decreased or discontinued if the hematocrit increases to above 50%.

Lipid disturbances in testosterone-treated male patients are generally not a problem because of the aromatization of testosterone to estradiol. The ratio of HDL to total cholesterol generally remains constant. Anabolic steroids, used in oral testosterone preparations, that are not aromatized increase LDL and lower HDL levels and thus could increase cardiovascular risk. An initial lipid profile should be recorded, and a follow-up profile should be obtained after 6 to 12 months of therapy and then yearly thereafter.
Sleep apnea may also be a problem in some men, and testosterone therapy should be discontinued until the sleep apnea problem can be adequately addressed . The patient should be asked about fatigue during the day in addition to disordered sleep. A sleep study should be done if symptoms are present. Because pharmacologic use of testosterone will suppress spermatogenesis, the use of testosterone preparations may substantially reduce fertility in otherwise normal men. This adverse effect is often an issue with the illicit use of testosterone.

Conclusion

The recognition, evaluation, and treatment of hypogonadism in the male patient are often dismissed by the patient and overlooked by the physician. The symptoms and signs of hypogonadism should be identified through appropriate questioning of the patient and a directed physical examination. Hormonal and ancillary testing should be performed in a cost-efficient and clinically appropriate manner to allow pertinent treatment considerations. Proper hormonal balance is essential to maintain optimal health.  Throughout your life, and particularly when you enter middle age, information about your body’s hormone production provides keen insights to help maintain a healthy and vigorous life.

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