Posts Tagged ‘hypogonadism’

Testosterone Treatment and Tiny Testicles: There is a Better Option

May 25, 2018

Andrew Siegel MD  5/25/18

“If a man is prescribed Food and Drug Administration approved testosterone for androgen deficiency, his overall health improves but his sperm production declines and his testes shrink. If he is prescribed off-label clomiphene citrate, his health improves and his sperm production is preserved, as does the size of his testicles.  This selective receptor estrogen modulator for male reproductive endocrine therapy must be a great new discovery, right? Wrong. It has been around for 50 years.”

Dr. Craig Niederberger, Department Head of Urology, University of Illinois School of Medicine

The Magic of Testosterone (T)

For the symptomatic man who has low levels of T, boosting levels of this male  “rocket fuel” 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 must 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.

T Science

Most T is made by the testicles. Its secretion is governed by the release of luteinizing hormone (LH) from the pituitary, the master gland in the brain. Some of T is converted to the female hormone estradiol (E). 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 Effect of Long-Term T Replacement

So, what happens when you have been on long-term T? This externally sourced 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, external T is a contraceptive! Nearly all men will have 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 sperm and natural T and after long-term T use, the testes can actually shrivel, becoming ghosts of their former functional selves. “Use it or lose it” is relevant to every organ in the body and external T essential puts the testes into hibernation and dormancy.

If you stop the T after long-term use, natural function does not resume anytime quickly. Although recovery usually occurs within 6 months or so, it may take several years and permanent detrimental effects are possible.

The bottom line is that at the time you are receiving the benefits of 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 50 years. 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. Here is a little secret: this medication also raises T levels nicely, and does so by stimulating the testes to secrete natural 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 really 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 commonly 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.

clomiphene-citrate-tablets

Works Like A Charm

CC usually works like a charm 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 laboratory testing. Using externally-sourced T to boost T successfully raises T and often resolves the symptoms of low T but shuts down the testes and nullifies whatever natural T was being produced as well as sperm production. Clomid is an oral, less expensive alternative that stimulates natural T production and the oral pill formulation is an easier and more discreet delivery system than sloppy gels, injections and pellets.

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 and a wonderful Memorial Day weekend,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

Advertisements

Obesity and Urology

April 5, 2013

Andrew Siegel, M.D.  Blog #101

A whopping two-thirds of adults in the USA are either overweight or obese.   In 1960 the obesity rate was 13%; currently it is 36%. Our physical activities have diminished, our stress levels and our portion sizes have increased, and our derrières have expanded accordingly.  There are an increasing abundance of readily available, unhealthy, processed, cheap foods.  These factors in sum have contributed to our weight gain and to a very negative impact on our overall health.  In addition to the more obvious increased risk for high cholesterol, high blood pressure, heart disease, stroke, and diabetes, weight gain and obesity are also associated with an increased incidence of gallstones, arthritis and other joint problems, sleep apnea and other breathing problems, as well as certain cancers. There are many other less obvious effects that obesity has, negatively impacting every system in our body.

Abdominal obesity—an accumulation of fat in our midsections—not only is unattractive from a cosmetic standpoint, but can have dire metabolic consequences that can affect the quality and quantity of our lives.  It is important to understand that fat is not merely the presence of excessive padding and insulation that signifies excessive intake of energy—but a metabolically active endocrine “organ” that does way more than just protrude from our abdomens, producing hormones and other chemical mediators that can have many detrimental effects on all systems of our body.  So, fat is not just fat. Today’s blog will focus on the harmful ramifications of weight gain and obesity on urological health. As a urologist, on a daily basis I sadly bear witness to the adverse effects and ill consequences of America’s bulging waistline.

Overactive bladder (OAB) is a common condition that causes urinary urgency, frequency, the need to run to the bathroom in a hurry, and at times urinary leakage before arrival at the bathroom. There is a clear-cut association between weight gain and the presence of OAB.   Similar to the way obesity taxes the joints, particularly the knees, so it burdens and puts pressure on pelvic organs including the urinary bladder.

Stress urinary incontinence (SUI) is a frequent ailment in adult women in which there is leakage of urine associated with a sudden increase in abdominal pressure, such as with sneezing, coughing, lifting, laughing, jumping, and any kind of strenuous exercise. Although the major risk factor is pregnancy, labor, and delivery, weight gain is clearly associated with exacerbating the problem.

Pelvic organ prolapse (POP) is a prevalent issue in adult women in which one or more of the pelvic organs—including the bladder, uterus, or rectum—drop down into the space of the vagina and possibly outside the vagina.  Similar in respect to stress urinary incontinence in that the major risk factor is pregnancy, labor and delivery, it is most certainly associated with weight gain and obesity, which have a negative effect on tissue strength and integrity.

Kidney stones are a major source of pain and disability and are very much associated with weight gain, obesity, and dietary indiscretion. Excessive protein and salt intake are unequivocal risk factors for the occurrence of kidney stones.   Uric acid stones, in particular, occur more commonly in overweight and obese people.  Beyond a certain weight limitation, “larger” patients cannot be treated with the standard, non-invasive shock wave lithotripsy to break up a kidney stone and urologists must, therefore, resort to more antiquated, more invasive, more risky measures.

Hypogonadism, a condition in which there are insufficient levels of the male sex hormone testosterone, is an increasingly prevalent condition that is associated with a host of negative effects. Obesity has a pivotal role in the process leading to low testosterone. One’s waist circumference is a reasonable proxy for low testosterone. Fat has an abundance of the hormone aromatase, which functions to convert testosterone to the female sex hormone estrogen.  The consequence of too much conversion of testosterone to estrogen is the potential for gynecomastia, a.k.a. “man boobs.”  Too much estrogen slows testosterone production and with less testosterone more abdominal obesity occurs and even more estrogen is made, a vicious cycle of emasculation and loss of libido.

Erectile dysfunction is a very prevalent condition associated with aging and numerous other risk factors. Weight gain and obesity are major contributors to poor quality rigidity and durability of erections.   This goes way beyond simply low testosterone levels.  Erections in essence are all about sufficient blood flow to the penis. Obesity contributes to problems with penile blood flow that can interfere in a major way with sexual function.   Additionally, as the abdominal fat pad grows, the penis seemingly shrinks and it is estimated that for every 35 pounds of weight gain, there is a 1-inch loss in apparent penile length. In fact, penile shrinkage is a very common complaint among my obese patients.

Prostate cancer is the most common cancer in men.  Like all cancers, prostate cancer is caused by mutations that occur during the process of cellular division.   Prostate cancer has a multifactorial basis, with both genetic and environmental factors at play. There is a clear association between a Western diet and the occurrence of prostate cancer.   This has been witnessed in Asian men, who have a relatively low incidence of prostate cancer in Asia, but after migrating to the USA and assuming a Western diet and lifestyle, have an incidence of prostate cancer that approaches that of Caucasians.

The obese patient presents a real challenge to the urological surgeon in terms of care both during and after an operation.  Surgery on overweight patients is more complex and takes longer as it is much more difficult to achieve proper exposure of the anatomical site being operated upon.  Surgery on obese patients has a higher complication rate with increased respiratory and wound problems. Anesthesiologists have more difficulty placing the breathing tube through a thick, obese neck, and greater difficulty with regional anesthesia as well, because of fatty tissue obscuring the landmarks to place the needle access for spinal anesthesia.

Bottom Line: Fat puts one at risk…for many very unfortunate potentialities.  Maintaining a healthy weight is an important priority for overall health, as well as our urological health.  The good news is that a lifestyle “remake” is typically the first line of treatment for many of the problems that I have just delved into and has the capacity of mitigating, if not reversing, some of them.  This involves the adoption of healthy eating habits, weight loss to achieve a healthy weight, and exercising on a regular basis.   

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.