Posts Tagged ‘low testosterone’

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.


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

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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


“Doc, My Penis Is Shrinking”

October 8, 2016

Andrew Siegel MD  10/8/16


Image above: Roman copy of Apollo Delphinios by Demetrius Miletus at the end of the second century (Attribution: Joanbanjo (Own work) [CC BY-SA 3.0 (, via Wikimedia Commons)

Not a day goes by in my urology practice when I fail to hear the following complaint from a patient: “Doc, my penis is shrinking.” The truth of the matter is that the penis can shrivel from a variety of circumstances, but most of the time it is a mere illusion—a sleight of penis, if you will. Weight gain and obesity cause a generous pubic fat pad, the male equivalent of the female mons pubis, which will make the penis appear shorter and retrusive. However, penile length is usually intact, with the penis merely hiding behind the fat pad, the “turtle effect.” Lose the fat and presto…the penis reappears. Having a plus-sized figure is not such a good thing when it comes to size matters, as well as many other matters.

Factoid: It is estimated that with every 35 lbs. of weight gain, there is one-inch loss in apparent penile length.

The 9-letter word every man despises: S-H-R-I-N-K-A-G-E, immortalized by Jason Alexander playing the character George in the Seinfeld series. Jerry’s girlfriend Rachel catches a glimpse of naked George after he has stepped out of a swimming pool. Suffice it to say that George’s penis was in a “non-optimized” state. George tries to explain: “Well I just got back from swimming in the pool and the water was cold.” Jerry makes the diagnosis: “Oh, you mean shrinkage” and George confirms: “Yes, significant shrinkage.”

Penis size has not escaped our “bigger is better” American mentality where large cars, homes, breasts,  buttocks and mega-logos on shirts are desirable and sought-after assets. The pervasive pornography industry–where many male stars are “hung like horses”– has given the average guy a bit of an inferiority complex.

Factoid: The reality of the situation is that the average male has an average-sized penis, but in our competitive society, although average is the norm, average curiously has gotten a bad rap.

Adages concerning penile size and function are common, e.g., “It’s not the size of the ship, but the motion of the ocean.” Or even better, as seen on a poster in a gateway while boarding an airplane: “Size should never outrank service.” The messages conveyed by these statements have significant merit, but nonetheless, to many men and women, size plays at least some role and many men have concerns about their size. Whereas men with tiny penises may be less capable of sexually pleasing a woman, men who have huge penises can end up intimidating women and provoking pain and discomfort.

Leonardo Da Vinci had an interesting take on perspectives: “Woman’s desire is the opposite of that of man. She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.”

Penile Stats

As a urologist who examines many patients a day, I can attest to the fact that penises come in all shapes and sizes and that flaccid length does not necessarily predict erect length and can vary depending upon many factors. There are showers and there are growers. Showers have a large flaccid length without significant expansion upon achieving an erection, as opposed to growers who have a relatively compact flaccid penis that expands significantly with erection.

With all biological parameters—including penis size—there is a bell curve with a wide range of variance, with most clustered in the middle and outliers at either end. Some men are phallically-endowed, some phallically-challenged, with most somewhere in the middle of the road. In a study of 3500 penises published by Alfred Kinsey, average flaccid length was 8.8 centimeters (3.5 inches). Average erect length ranged between 12.9-15 centimeters (5-6 inches). Average circumference of the erect penis was 12.3 centimeters (4.75 inches). As with so many physical traits, penis size is largely determined by genetic and hereditary factors. Blame it on your father (and mother).

Factoid: Hung like a horse—forget about it! The blue whale has the mightiest genitals of any animal in the animal kingdom: penis length is 8-10 feet; penis girth is 12-14 inches; ejaculate volume is 4-5 gallons; and testicles are 100-150 pounds. Hung like a whale!

Factoid: “Supersize Me.” In order to make their genitals look larger, the Mambas of New Hebrides wrap their penises in many yards of cloth, making them appear massive in length. The Caramoja tribe of Northern Uganda tie weights on the end of their penises in efforts to elongate them.

“Acute” Shrinkage

Penile size in an individual can be quite variable, based upon penile blood flow. The more blood flow, the more tumescence (swelling); the less blood flow, the less tumescence. “Shrinkage” is a real phenomenon provoked by exposure to cold (weather or water), the state of being anxious or nervous, and participation in sports. The mechanism in all cases involves blood circulation.

Cold exposure causes vasoconstriction (narrowing of arterial flow) to the body’s peripheral anatomy to help maintain blood flow and temperature to the vital core. This principle is used when placing ice on an injury, as the vasoconstriction will reduce swelling and inflammation. Similarly, exposure to heat causes vasodilation (expansion of arterial flow), the reason why some penile fullness can occur in a warm shower.

Nervous states and anxiety cause the release of the stress hormone adrenaline, which functions as a vasoconstrictor, resulting in numerous effects, including a flaccid penis. In fact, when the rare patient presents to the emergency room with an erection that will not quit, urologists often must inject an adrenaline-like medication into the penis to bring the erection down.

Hitting it hard in the gym or with any athletic pursuit demands a tremendous increase in blood flow to the parts of the body involved with the effort. There is a “steal” of blood flow away from organs and tissues not involved with the athletics with “shunting” of that blood flow to the organs and tissues with the highest oxygen and nutritional demands, namely the muscles. The penis is one of those organs from which blood is “stolen”—essentially “stealing from Peter to pay Paul” (pun intended!)—rendering the penis into a sad, deflated state. Additionally, the adrenaline release that typically accompanies exercise further shrinks the penis.

Cycling and other saddle sports—including motorcycle, moped, and horseback riding—put intense, prolonged pressure on the perineum (area between scrotum and anus), which is the anatomical location of the penile blood and nerve supply as well as pelvic floor muscles that help support erections and maintain rigidity.  Between the compromise to the penile blood flow and the nerve supply, the direct pressure effect on the pelvic floor muscles, and the steal, there is a perfect storm for a limp, shriveled and exhausted penis. More importantly is the potential erectile dysfunction that may occur from too much time in the saddle.

“Chronic” Shrinkage

Like any other body part, the penis needs to be used on a regular basis—the way nature intended—in order to maintain its health. In the absence of regular sexual activity, disuse atrophy (wasting away with a decline in anatomy and function) of the penile erectile tissues can occur, resulting in a “de-conditioned,” smaller and often temperamental penis.

Factoid: If you go for too long without an erection, smooth muscle, elastin and other tissues within the penis may be negatively affected, resulting in a loss of penile length and girth and negatively affecting ability to achieve an erection.

Factoid: Scientific studies have found that sexual intercourse on a regular basis protects against ED and that the risk of ED is inversely related to the frequency of intercourse. Men reporting intercourse less than once weekly had a two-fold higher incidence of ED as compared to men reporting intercourse once weekly.

Radical prostatectomy as a treatment for prostate cancer can cause penile shrinkage. This occurs because of the loss in urethral length necessitated by the surgical removal of the prostate, which is compounded by the disuse atrophy and scarring that can occur from the erectile dysfunction associated with the surgical procedure. For this reason, getting back in the saddle as soon as possible after surgery will help “rehabilitate” the penis by preventing disuse atrophy.

Peyronie’s Disease can cause penile shrinkage on the basis of scarring of the erectile tissues that prevents them from expanding properly.  For more on this, see my blog on the topic:

Medications that reduce testosterone levels are often used as a form of treatment for prostate cancer. The resultant low testosterone level can result in penile atrophy and shrinkage. Having a low testosterone level from other causes will also contribute to a reduction in penile size.

Are There Herbs, Vitamins or Pills That Can Increase Penile Size?

Do not waste your resources on the vast number of heavily advertised products that will supposedly increase penile size but have no merit whatsoever.  Realistically, the only medications capable of increasing penile size are the oral medications that are FDA approved for ED. Daily Cialis will increase penile blood flow and by so doing will increase flaccid penile dimensions over what they would normally be; the erect penis may be larger as well because of augmented blood flow.  Additionally, for many men this will restore the capability of being sexually active whereas previously they were unable to obtain a penetrable erection, thus allowing them to “use it instead of losing it” and maintain healthy penile anatomy and function.

Is Penile Enlargement Feasible Through Mechanical Means?

It is possible to increase penile size using tissue expansion techniques. The vacuum suction device uses either a manual or battery-powered source to create a vacuum in a cylinder into which the penis is placed. The negative pressure pulls blood into the penis, expanding penile length and girth. A constriction ring is placed around the base of the penis to maintain the erection. The vacuum is used to manage ED as well as a means of penile rehabilitation and is also used prior to penile implant surgery to increase the dimensions of the penis and allow a slightly larger device to be implanted than could be used otherwise. It can also be helpful under circumstances of penile shrinkage.


Vacuum Suction Device

The Penimaster Pro is a penile traction system that is approved in the European Union and Canada for urological conditions that lead to shortening and curvature of the penis. In the USA it is under investigation by the FDA. It is a means of using mechanical stress to cause penile tissue expansion and enlargement.


Penimaster Pro

What’s The Deal With Penile Enlargement Surgery?

Some men who would like to have a larger penis may consider surgery. In my opinion, penile enlargement surgery, aka, “augmentation phalloplasty,” is highly risky and not ready for prime time. Certain procedures are “sleight of penis” procedures including cutting the suspensory ligaments, disconnecting and moving the attachment of the scrotum to the penile base, and liposuction of the pubic fat pad. These procedures unveil some of the “hidden” penis, but do nothing to enhance overall length. Other procedures attempt to “bulk” the penis by injections of fat, silicone, bulking agents, tissue grafts and other implantable materials. The untoward effects of enlargement surgery can include an unsightly, lumpy, discolored, painful and perhaps poorly functioning penis. Realistically, in the quest for a larger member, the best we can hope for is to accept our genetic endowment, remain physically fit, and keep our pelvic floor muscles well conditioned.

What’s Up With Penile Transplants?

The world’s first penis transplant was performed at Guangzhou General Hospital in China when microsurgery was used to transplant a donor penis to a recipient whose penis was damaged beyond repair in an accident. Subsequently, there have been several transplants done for penile trauma.  Hmmm, now here is a concept for penile enlargement!

What To Do To Avoid Shrinkage issues?

  • Accept that cold, stress and athletics will cause temporary shrinkage
  • Be aware that cycling and other saddle sports can cause shrinkage as well as erectile dysfunction: wear comfortable and protective shorts; get measured for a saddle with an appropriate fit; frequently rise up out of the saddle, taking the pressure off the perineum
  • Eat a healthy diet and stay physically active to maintain a lean physique
  • Use it or lose it: stay sexually active
  • Do pelvic floor exercises (a.k.a. Man Kegels): visit
  • “Rehab” the penis to avoid disuse atrophy after radical prostatectomy: oral ED meds, pelvic floor muscle training, vibrational stimulation, vacuum suction device, penile injection therapy; consider “pre-hab” before the surgery
  • Seek urological care for Peyronie’s disease

Wishing you the best of health,

2014-04-23 20:16:29

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Man-Oh-Pause: When Things Are Not So Good Under The Hood

September 1, 2012

Blog #73     Andrew Siegel, M.D.


“T”  (an abbreviation for testosterone) has become a very commonly used and in vogue term. Many of my patients come into the office specifically asking for their T levels to be checked.  The pharmaceutical industry has been responsible for direct-to-consumer advertising of testosterone replacement products, a practice that has promoted this recent grass-roots awareness of testosterone issues, a subject that was previously the domain of urologists and endocrinologists.

T is that all-important male hormone that goes way beyond male sexuality.  Testosterone has moved to the endocrine vanguard and is now regarded as a key factor in men’s health. Current evidence suggests that a man’s testosterone level might serve a function as a good indicator/marker of general male health.

Aside for contributing to libido, masculinity and sexual function, T is responsible for the physical changes that commence at the time of puberty, including pubic, axillary and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass.  Additionally, T contributes to our mood, bone and muscle strength, red blood cell count, energy, and general mojo.  Most testosterone is manufactured in the testicles, although a small percentage is made by the adrenal glands.

There is a gradual decline in T that occurs with the aging process—approximately a 1% decline each year after age 30.  This will occur in most men, but will not always be symptomatic.  40% of American men aged 45 or older have low or low range T.  Low T is associated with metabolic syndrome and diabetes, bone mineral loss, and altered sexual function.  Specifically, symptoms of low T may include one or more of the following:  fatigue; irritability; depression; decreased libido; erectile dysfunction; impaired orgasmic function; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; abnormal lipid profiles. Essentially, low T can accelerate the aging process.

Belly fat is literally the enemy of masculinity and a testosterone-choker that can push you in the direction of the female gender.  Perhaps when you are standing naked in the shower and you gaze down towards your feet, all you see is the protuberant roundness of your large midriff, obscuring the sight of your manhood.  Perhaps you’re wondering where your penis is hiding.  In most cases, the abundant pubic fat pad that occurs coincident with weight gain obscures the penis—the “turtle effect.”  If your belly blocks your view of your penis, your pubic fat pad makes your penis difficult to locate, your breasts have filled out, and your libido and erections are sub-par, it may just really be time to rethink your lifestyle habits!

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. Obesity has a pivotal role in the process leading to low T and waist circumference is a reasonable proxy for low T. Fat is not just fat—it is a metabolically active endocrine organ that does way more than just protrude from our abdomens.  Fat has an abundance of the hormone aromatase, which functions to convert T to the female sex hormone estrogen (E).  The consequence of too much conversion of T to E is the potential for gynecomastia, aka man boobs.  Too much E slows T production, and with less T, more abdominal obesity occurs and even more E is made, a vicious cycle (literally a vicious circus) of male castration and emasculation.

Obesity can steal away your masculinity, male athletic form and body composition, mojo, strength, and also one of your most precious resources—the ability to obtain and maintain a good quality erection.  Remember the days when you could achieve a majestic, heaven-pointing erection simply by seeing an attractive woman or thinking some vague sexual thought?  Chances were that you were young, physically active, and had a svelte build with a hard abdomen. If those days are mere memories, it is probable that you are now carrying extra pounds, have a soft and protuberant belly, and are not physically active.  When you’re soft in the middle, the consequence is that you will probably be soft down below. The good news is that by losing the abdominal fat, the unfortunate consequences of low T can often be reversed.

How To Turn On Your Testosterone Boosters: 

  • A healthy lifestyle, including good eating habits, maintaining a healthy weight, engaging in exercise, obtaining adequate sleep, moderation with respect to alcohol intake, avoiding tobacco, and stress reduction are the initial approaches to treating low T engendered by abdominal obesity.  Insufficient sleep can lower T.  Excessive alcohol increases the conversion of T to E.  Maintaining an active sex life can help maintain T.
  • It is of paramount importance to lose the abdominal fat, with the caveat that a sufficient caloric intake of quality food and nutrients is necessary to prevent the body going into “starvation mode,” which can substantially decrease T production.
  • In terms of exercise, a healthy balance of aerobic, resistance, and core training is best, but in particular, vigorous resistance exercise is crucial.  This will help the flabby abdomen disappear and build lean muscle mass, which in turn will increase metabolic rate.

If lifestyle modification fails to improve the symptoms of low T and T remains measurably low via a simple blood test, a trial of T replacement under the supervision of your doctor can provide a meaningful improvement of your quality of life.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

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