Testosterone Replacement Therapy for Men
Yes. What your may be experiencing could be a perfectly natural part of aging. Andropause, a syndrome in aging men, consists of physical, sexual, and psychologic symptoms that include weakness, fatigue, reduced muscle and bone mass, impaired hematopoiesis, oligospermia, sexual dysfunction, depression, anxiety, irritability, insomnia, memory impairment, and reduced cognitive function.
Signs of Andropause
Symptoms of low testosterone:
- Decreased mental quickness and sharpness
- Decreased energy, strength and endurance
- Less desire for activity and exercise
- Night sweats and trouble sleeping
- Decreased muscle and increased body fat
- Mild to moderate depression and irritability
- Depression and/or loss of eagerness and enthusiasm for daily life
- Decreased sex drive
- Decreased sexual function and/or sensitivity
Male patients don’t usually recognize the symptoms of testosterone deficiency until it effects their erections. They often ignore the preliminary health related problems that occur as a result of age related declining testosterone levels. “But I can still perform in bed Doc!” “I can’t be testosterone deficient”.
Many a male patient has taken offense to my recommendation that we test their hormone levels. They respond like I just accused them of wearing thong underwear. This is all too common the response, and a sad one at that. Are you a professional that relies on a sharp mind for your job, yet yours is failing you? Or maybe you are hard physical worker that relies on your stamina to keep the pay checks coming in, yet your abilities are failing you.
Symptoms of Testosterone Deficiency (Androgen Deficiency):
- Loss of energy
- Brain Fog
- Decrease mental quickness
- Diminished libido
- Decrease orgasmic intensity
- Loss of strength
- Loss of muscle flexibility
- Prolonged recovery from exercise
- Loss of cardiac protection
- High cholesterol
- High LDL Cholesterol
- Weight gain
- Fat increase especially mid abdominal
- Loss of endurance Depression
- Sleep disturbances
- Difficulty converting fat to lean muscle mass with increased exercise
With an ever growing epidemic of Diabetes and Metabolic syndrome, patients think that losing sight of their knees underneath their growing abdominal fat fold is a normal part of aging. Well it isn’t! It is the result of poor nutrition, increased visceral fat, and declining hormone systems. Testosterone is an important part of homeostasis, also known as “Physiological Balance” Interestingly enough, testosterone is important for both men and women. As is obvious, it is a very important hormone in the male body. While the sex organs have testosterone receptors, the heart muscle has a very high density of testosterone receptors. So while decreased libido may be commonly recognized as a sign of testosterone deficiency, many other physiological processes are also affected, and much sooner in the deficiency state than that of sex drive.
Testosterone levels begin to decline at 30 years of age, and the typical male’s testosterone declines by approximately 10% per decade. This age related decline is a variable utilized by laboratories to calculate free testosterone levels. What does this mean? This means when a patient’s physician orders a testosterone level, the lab provides a “free testosterone” level. This level is based on a calculation that utilizes age related decline as a “normal” factor. What isn’t recognized, is that the levels a patient had as 20-30 year old man should be considered optimal for that individual. Not a calculation that takes into account all the other deficient males at that age level. Health was optimal at 30 years of age.
Testosterone is a hormone that is carried in the blood stream by a protein known as Sex Hormone Binding Globulin (SHBG). If patient doesn’t suffer from malnutrition, this protein binds testosterone. However, at cellular levels, it is the free unbound testosterone that engages testosterone receptors. Therefore, if a person’s SHBG levels are elevated, and their total testosterone levels are normal to low, the amount of available free testosterone able to engage the receptors may be negligible.
What does this mean? This means to get an accurate picture of “free testosterone” levels, the SHBG levels must be tested. Most physicians don’t do this, and most insurance companies don’t encourage it. An even scarier occurrence: As a man gains more body fat, this fat harbors an enzyme called aromatase. Aromatase is an enzyme that converts testosterone into estrogen. So as we gain mid abdominal fat and as we age, we slowly increase our estrogen levels, thus becoming a woman. It is the aromatase that enhances the vicious cycle of mid abdominal fat. Unfortunately this mid abdominal fat, also called visceral fat, secretes a hormone called Leptin. Leptin is a hormone that communicates with the hypothalamus in the brain and is engaged in satiety signally, or the feeling that we are “full” after a meal. When our body over secrets Leptin, we develop Leptin resistance. Akin to insulin resistance, the two of these syndromes throw us into the spiral of weight gain, health problems, and diabetes.
Introduction To Male Testosterone
Testosterone is responsible for normal growth and development of male sex organs and maintenance of secondary sex characteristics. It is the primary androgenic hormone.
When the testes fail to produce normal levels of testosterone, testosterone deficiency results. Hypogonadism is caused by primary testicular failure. Testosterone levels are low and pituitary gonadotropins are elevated. In hypogonadism, there is inadequate secretion of pituitary gonadotropins. In addition to a low testosterone level, LH and FSH levels are low or low-normal. The development of hypogonadism after puberty frequently results in complaints such as diminished libido, erectile dysfunction, infertility, gynecomastia, changes in body composition, reductions in body and facial hair, and osteoporosis. Hypogonadal men report higher levels of anger, confusion and depression.
There are now a variety of products available to treat testosterone deficiency. Successful management of testosterone replacement therapy requires appropriate evaluation and an understanding of the benefits and risks of treatment.
Proper Diagnosis of Testosterone Deficiency
There are many causes of testosterone deficiency, a medical history, physical exam, and the proper laboratory evaluation are imperative. The medical history should be questions regarding abnormalities at birth, the current status of sexual function and secondary sexual characteristics, such as beard growth, muscular strength, and energy level. Hypogonadal men have statistically significant reductions in the incidence of nocturnal erections, the degree of penile rigidity during erection, and the frequency of sexual thoughts, feelings of desire, and sexual fantasies. Furthermore, alterations in body composition, changes in adipose tissue, increases in percent body fat and reduction in muscle mass, are frequently seen in hypogonadal men.
Proper Labs should be drawn to determine a diagnosis. The following levels should be drawn in the morning. FSH, LH, SHBG, Total and Free Testosterone, Estradiol and Estrone.
The Clinical rational for Testosterone Replacement Therapy
Testosterone replacement should in theory approximate the natural, endogenous production of the hormone. The average male produces 4-7 mg of testosterone per day in a circadian pattern, with maximal plasma levels attained in early morning and minimal levels in the evening.
The clinical rationale for treatment of testosterone deficiency may include:
- Increasing bone density
- enhancing body composition by increasing muscle strength and reducing adipose
- improving energy and mood
- improving libido and erectile function
Types of Testosterone Replacement Therapy
Ideal testosterone replacement therapy produces and maintains physiologic serum concentrations of the hormone and its active metabolites without significant side effects or safety concerns. Several different types of testosterone replacement are currently marketed, including tablets, injectables, sublingual, transdermal, and Pellet insertion.
Oral agents may cause elevations in liver function tests and abnormalities at liver scan and biopsy. Both modified and unmodified oral testosterone preparations are available. Unmodified testosterone is rapidly absorbed by the liver, making satisfactory serum concentrations difficult to achieve. Modified 17-alpha alkyltestosterones, such as methyltestosterone or fluoxymesterone, also require relatively large doses that must be taken several times a day.
Testosterone cypionate and enanthate are frequently used parenteral preparations that provide a safe means of hormone replacement in hypogonadal men. In men 20-50 years of age, an intramuscular injection of 200 to 300 mg testosterone enanthate is generally sufficient to produce serum testosterone levels that are supranormal initially and fall into the normal ranges over the next 14 days. Fluctuations in testosterone levels may yield variations in libido, sexual function, energy, and mood. Some patients may be inconvenienced by the need for frequent testosterone injections.1Increasing the dose to 300 to 400 mg may allow for maintenance of eugonadal levels of serum testosterone for up to three weeks, but higher doses will not lengthen the eugonadal period.
Sublingual testosterone is placed under the tongue and is usually in the form of a square or circle, depending on strength of troche. A sublingual dose is given twice a day, same as the transdermal therapy below. It by-passes the liver and takes about 2 to 3 minutes to melt. The taste is generally bitter but the compounding pharmacies will flavor it to mask the bitterness somewhat. Testosterone levels will peak and drop on this therapy; this is why it would be best to take it two or three times a day in smaller doses.
Clinical studies of transdermal systems demonstrate their efficacy in providing adequate testosterone replacement therapy. Transdermal therapy can be made in a cream or gel by a compounding pharmacy. Different strengths are used, ranging from 10mg to 200mg per ml. A daily dose is given in the early morning hours. For best results of maintaining physiologic testosterone levels you would want to take testosterone twice a day early am (5am to 7am) and again around (1 to 4pm).
Monitoring Patients on Testosterone Replacement
Patients on testosterone replacement therapy should be monitored to ensure that testosterone levels are within normal levels. The physician prescribing testosterone replacement should evaluate any changes in the clinical symptoms and signs of testosterone deficiency and should assess for other concerns, such as acne and increase in breast size and tenderness. Serum testosterone levels should be checked between 5 to 7 hours after application of a transdermal or sublingual delivery systems.
A prostate specific antigen (PSA) checked in all men before initiating treatment. These should be repeated at approximately three to six months, and then annually in men >40 years of age. A confirmed increase in PSA >2 ng/mL, or a total PSA >4.0 ng/mL requires urologic evaluation. The hematocrit level should also be checked at baseline, at three to six months, and then annually. A hematocrit >55% warrants evaluation for hypoxia and sleep apnea and/or a reduction in the dose of testosterone therapy. Measurement of bone mineral density of the lumbar spine and/or the femoral necks at one year may be considered in hypogonadal men with osteopenia.
Benefits of Testosterone Replacement Therapy
A number of benefits of testosterone replacement therapy have been recorded, including better stability with moods, energy levels, and libido. Testosterone replacement has also been shown to enhance libido and the frequency of sexual acts and sleep-related erections. Transdermal testosterone replacement therapy, in particular, has been linked to positive effects on fatigue, mood, and sexual function, as well as significant increases in sexual activity. More specifically, testosterone replacement therapy has been shown to improve positive mood parameters, such as feeling of friendliness, reducing negative mood parameters, such as anger and irritability.
Testosterone replacement therapy is also associated with potentially positive changes in body composition. In hypogonadal men, testosterone replacement therapy has demonstrated a number of effects, including an increase in lean body mass and decrease in body fat, and increases in muscle size.
Testosterone replacement with transdermal testosterone delivery systems in HIV-infected men with low testosterone levels has been associated with statistically significant gains in lean body mass (p=0.02), increased red cell counts, and improvements in emotional distress. Transdermal testosterone has also been administered to HIV-positive women, yielding positive trends in weight gain and quality of life.
Improvements in bone density have also been shown with testosterone replacement therapy. Increases in spinal bone density have been realized in hypogonadal men, with most treated men maintaining bone density above the fracture threshold.
Contraindications to Testosterone Replacement Therapy
Testosterone replacement is contraindicated in men with carcinoma of the breast or known or suspected carcinoma of the prostate, as it may cause rapid growth of these tumors. Hormone therapy is also inappropriate in men with severe benign prostatic hypertrophy (BPH)-related bladder outlet obstruction. Use of testosterone to improve athletic performance or correct short stature is potentially dangerous and inappropriate.
Hormone Replacement Therapy for Men
Hormone Replacement Therapy is for men too. You are not alone in this. Biologically equivalent Hormone Replacement therapy achieves the sustained levels of testosterone that would be produced by normally functioning testicles. This form of therapy is the only kind that produces the natural level of hormone that men need. Because the testosterone used is totally natural, it is ideal for men wanting the benefits of a bio-equivalent hormone, without the drawbacks of a synthetic.
Symptoms of testosterone deficiency in men include fatigue, lack of mental acuity, loss of libido, and difficulty achieving, or sustaining erection.
Why Biologically equivalent Hormone therapy for men? Hormonal needs for men has received national attention, but with marginal treatment options available. Hormonal treatments for men can be expensive, require daily consumption, and in many cases, need to be carefully timed with their partner’s needs for normal sexual activities and pleasure.
Biologically equivalent hormone therapy administered by Dr. Zimmerman is the only method of testosterone therapy that gives sustained and consistent testosterone levels throughout the day, for 4 to 6 months, without any “roller coaster” blood levels of testosterone, which can result in mood and energy fluctuations for the patient.
Dr. Zimmerman has had excellent results treating men with Biologically equivalent Hormone therapy. There have been no reported side effects in the entire history of this type of therapy.
Current medical research now defines a male equivalent to menopause referred to as andropause. Men experience a more gradual decline in hormone levels. They lose approximately one percent of their testosterone and 2.5 percent of the DHEA per year beginning at age 30.
Men find themselves lacking in sexual desire, gaining weight, losing muscle mass and feeling sluggish, depressed and irritable. Yet, they believe they must endure these body and hormonal changes as part of aging. Together, we can change that misconception.