Andrew Siegel MD 1/10/15
The Magic Of T
You probably have heard a great deal about T (testosterone) and its extraordinary properties and indeed, for the symptomatic man who has low levels of T, boosting levels of this hormone can result in a remarkable improvement of energy, sexuality (sex drive, erections, ejaculation), masculinity, mood, body composition (muscle and bone mass), mental focus and other parameters. However, men considering T treatment need to understand that T is not a cure-all and must only be used under the circumstances of symptoms of low T and laboratory testing that shows low T. Most certainly, T has been over-marketed, over-prescribed and certain side effects have been understated. It is vital to understand the side effects of T before committing to treatment.
Some Necessary Science
Most T is made by the testicles. Its secretion is governed by the release of LH (luteinizing hormone) from the pituitary, the master gland within your brain. Some of T is converted to E (estradiol). E is the primary hormone involved in the regulation of the pituitary gland. Under the circumstance of adequate levels of T, E feeds back to the pituitary to turn off LH production. This feedback loop is similar to the way a thermostat regulates the temperature of a room in order to maintain a relatively constant temperature, shutting the heat off when a certain temperature is achieved, and turning it on when the temperature drops.
The Effects of Being on Long-Term Testosterone Replacement
So what happens when you have been on long-term T? This exogenous (external source) T, whether it is in the form of gels, patches, injections, pellets, etc., shuts off the pituitary LH by the feedback system described above so that the testes stop manufacturing natural T. Additionally, the testes production of sperm is stifled, problematic for men wishing to remain fertile. In other words, exogenous T is a contraceptive! Nearly all men will have some level of suppression of sperm production while on T replacement, less so with the gels vs. the injections or implantable pellets.
Thus, using T results in the testes shutting down production of natural T and sperm and after long-term T use, the testes can actually shrivel, becoming ghosts of their former functional selves. And if you stop the T after long-term use, natural function does not resume anytime quickly. Although recovery of natural testosterone and sperm production after stopping T replacement usually occurs within 6 months or so, it may take several years and permanent detrimental effects are possible. So, at the time that you are receiving the benefits of exogenous T, your natural T is shut off and you can end up infertile, with smaller testicles (testicular atrophy, in urology parlance)!
Is there an alternative for the symptomatic male with low T? Can you boost levels of T without shutting down your testes and developing shrunken, poorly functional gonads?
The answer is an affirmative YES, and one that Big Pharma does not want you to know. There has been such a medication around for quite some time. It has been FDA approved for infertility issues in both sexes and is available on a generic basis. In urology we have used it for many years for men with low sperm counts. But here is a little secret: this medication also raises T levels nicely, and does so by triggering the testes to secrete natural T. It works by stimulating the testes to make its own T rather than shutting them down. No marble-sized testes that have their function turned to the “off” mode, but respectable family jewels. The other good news is that treatment does not necessarily need to be indefinite. The testes can be “kicked” back into normal function, and at some point a trial off the medication is warranted.
The medication is clomiphene citrate, a.k.a, Clomid, and I will refer to it as CC. CC is an oral pill often used in females to stimulate ovulation and in males to stimulate sperm production. CC is a selective estrogen receptor modulator (SERM) and works by increasing the pituitary hormones that trigger the testes to produce sperm and testosterone. CC blocks E at the pituitary, so the pituitary sees less E and makes more LH and thus more T, whereas giving external T does the opposite, increasing E and thus the pituitary makes less LH and the testes stop making T.
Works Like A Charm
CCis usually effective in increasing T levels and maintaining sperm production, testes anatomy (size) and function. Its safety and effectiveness profile has been well established and minor side effects occur in proportion to dose and may include (in a small percentage of men): flushes, abdominal discomfort, nausea and vomiting, headache, and rarely visual symptoms. In general, those with the highest LH levels have the poorest response to CC, probably because they already have maximal stimulation of the testes by the LH.
Not FDA Approved For Low T
One issue is that CC is not FDA approved for low T, only for infertility. Many physicians are reluctant to use a medication that is not FDA approved for a specific purpose. It needs to be used “off label,” even though it is effective and less expensive than most of the other overpriced T products on the market.
Bottom Line: Treatment to boost T levels should only be done when one has genuine symptoms of low T and a low T level documented on lab testing. It is imperative to monitor those on such treatment on a regular basis. Using T to boost T can result in shutting down the testes and the possibility of atrophied, non-functional testes that do not produce sperm or natural testosterone. CC is an oral, less expensive alternative that stimulates natural T production.
A study from Journal of Urology (Testosterone Supplementation Versus Clomiphene Citrate: An Age Matched Comparison of Satisfaction and Efficiency. R. Ramasamy, JM Scovell, JR Kovac, LI Lipshultz in J Urol 2014;192:875-9) compared T injections, T gels, CC and no treatment. T increased from 247 to 504, 224 to 1104 and 230 to 412 ng/dL, respectively, for CC, T injections and gels. Men in all of the 3 treatment arms experienced similar satisfaction. The authors concluded that CC is equally effective as T gels with respect to T level and improvement in T deficiency-related clinical symptoms and because CC is much less expensive than T gels and does not harm testes size or sperm production, physicians should much more often consider CC, particularly in younger men with low T levels.
Wishing you the best of health,
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Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: http://www.MalePelvicFitness.com
Co-creator of Private Gym pelvic floor muscle training program for men: http://www.PrivateGym.com