Posts Tagged ‘T’

What You Don’t Know About Testosterone Treatment…and Perhaps A Better Option

January 10, 2015

Andrew Siegel MD  1/10/15

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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,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

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 menhttp://www.PrivateGym.com

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Testosterone: Not Just For Men; Estrogen: Not Just For Women

October 5, 2013

Andrew Siegel MD Blog # 122

What’s going on with the unrelenting direct–to-consumer television advertising for medications?  On television and radio we are bombarded with ads for drugs for the “ABC” diseases—ED (erectile dysfunction), OAB (overactive bladder), low T (testosterone).  What’s all this hubbub about T (testosterone) anyway?  Why is T suddenly so special, so hot and trendy, the hormone de jour, the “new” Viagra?  Is this for real or mere media hype?

Medicine is truly in its “infancy” with respect to its understanding of the male and female sex hormones, testosterone (T) and estrogen (E), respectively. Not too long ago it was dogma that T was solely the male hormone and that E was solely the female hormone.  As is often the case in science, “dogma” turns to “dog crap” with time, research, and progressive understanding.

Dr. Joel Finkelstein, in the September 13, 2013 New England Journal of Medicine, disrupted the endocrine status quo and provided the scientific basis for the major importance of both T and E for male health and wellness (and there is little doubt that both E and T are also equally crucial for female health and wellness). His study clearly demonstrated that muscle size and strength are controlled by T; fat accumulation is primarily regulated by E; and sexual function is determined by both T and E.

Some basics about T:

In the life of the male embryo, T is first produced during the mid-first trimester, and this hormonal surge causes the male external genitalia (penis and scrotum) and internal genitalia (prostate, seminal vesicles, etc.) to develop. In the absence of T, the fetus becomes a female, making the female gender the “default” sex. Dihydrotestosterone (DHT) is the activated form of T required by the fetus to initiate the development of male physical characteristics. In the absence of DHT, male genitalia do not develop.  DHT is far more potent than T and is the hormone that also gives rise—much later in life—to male pattern baldness and the condition of benign prostate enlargement.

T is produced mostly in the testes, although the adrenal glands also manufacture a small amount. T has a critical role in male development and physical characteristics. It promotes tissue growth via protein synthesis, having “anabolic” effects including building of muscle mass, bone mass and strength, and “androgenic” (masculinizing) effects at the time of puberty.  With the T surge at puberty many changes occur: penis enlargement; development of an interest in sex; increased frequency of erections; pubic, axillary, facial, chest and leg hair; decrease in body fat and increase in muscle and bone mass, growth and strength; deepened voice and prominence of the Adam’s apple; occurrence of fertility; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and transition from “cute” baby face to “angular” adult face.  Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.

Thanks to the advertising of Big Pharma, patients now come to the office requesting—if not demanding—to know what their T levels are. Prescriptions for T have increased exponentially over the last five years, creating a $2 billion industry with numerous pharmaceutical companies competing for a piece of the lucrative T pie, as the cost of the product is minimal and the markup is prodigious.  Little did Butenandt and Hanisch—who earned the Nobel Prize in chemistry for their synthesis of testosterone from cholesterol way back in 1939—know of what their discovery would lead to 70 years later!

Who Knew? Humans manufacture T using cholesterol as a precursor, so don’t be under the delusion that all cholesterol is bad. However, don’t get carried away consuming cholesterol-laden foods reasoning that the Big Mac with cheese will raise your T.

T can bind to specialized receptors that are present in many cells in the body and exert numerous anabolic and androgenic effects; alternatively, T can be converted to 5-DHT  (the active form of T) or can be converted to estradiol—a form of E—by the chemical process of aromatization. More than 80% of E in men is derived from T as a source. When levels of T are low, there is a decline in E levels. E deficiency is important in terms of osteopenia (bone thinning) in both men and women.

Dr. Finkelstein’s study was really a more sophisticated and quantitative take on the original study by organic chemist Professor Fred Koch at the University of Chicago in 1927, this time using humans instead of animals, and quantitating the effect of the T replacement as opposed to a qualitative assessment. Professor Koch used capons—roosters castrated surgically (having their testes removed) at a young age.  He then injected them with a substance obtained from bull testicles—readily available from the Chicago stockyards—which essentially was T.   After injecting the capons with this extraction, the capons crowed like roosters, a feat that capons are incapable of.  When the study was repeated in castrated pigs and rats, the substance was found to re-masculinize them as well.  Unlike Professor Koch, who used surgically castrated animals, Dr. Finkelstein used humans who were temporarily “castrated” via a reversible medication.

In Dr. Finkelstein’s study, as reported in the NEJM, there were 2 groupings of 5 populations of men. Both groupings had their T production blocked chemically. One population was given no replacement T, another 1.25 grams T daily, another 2.5 grams T daily, another 5 grams T daily, and the last group 10 grams T daily. The average serum T and E levels of each population were the following: no testosterone replacement: 44/3.6; 1.25 grams: 191/7.9; 2.5 grams: 337/11.9; 5 grams: 470/18.2; 10 grams 805/33. The second grouping of 5 populations had their E blocked as well.  Testing was done to see the effects of T and E levels on lean mass, muscle size and strength, fat mass, and sexual function.

By looking at the aforementioned numbers, one can see a direct relationship between T dose and serum level of both T and E.  The higher the T dose, the greater is the serum T and E.  The study concluded that lean mass, muscle size and strength were T dose-dependent, meaning the higher the T, the more the lean mass, muscle size and strength.  Additionally, fat mass was seen to be E dose-dependent and sexual function was both T and E responsive.

Dr. Finkelstein concluded that E deficiency in men is a manifestation of severe T deficiency and is remediable by T replacement. Fat accumulation seems to occur with a mild T deficiency (T measurements in the 300-350 range); muscle mass and muscle strength are preserved until a more marked T deficiency (T <200) occurs.   E was shown to have a fundamentally important role in the regulation of body fat and sexual function and evidence from previous studies demonstrated a crucial role for E in bone metabolism. Therefore, low T is not just about low T, but is also about E deficiency, which is responsible for some of the key consequences of T deficiency. Measuring levels of E are helpful in assessing sexual dysfunction, bone loss, and fat accumulation in men with low T.

The amount of T made is regulated by the hypothalamus-pituitary-testicular axis, which acts like a thermostat to regulate the levels of T.  Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon. T levels can be low based upon testicular problems or hypothalamus/pituitary problems, although the problem most commonly is due to the aging testicle’s inability to manufacture sufficient levels of T.  T levels gradually decline—approximately a 1% decline each year after age 30—sometimes giving rise to symptoms.  These symptoms may include the following: fatigue; irritability; decreased cognitive abilities; depression; decreased libido; ED; ejaculatory dysfunction; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; and abnormal lipid profile. A simple way to think about the effect of low T is that it accelerates the aging process.

T is commonly prescribed for T deficiency when it becomes symptomatic. There are many means of testosterone replacement therapy (TRT).  Oral replacement is not used because of erratic absorption and liver toxicity. Injections are not the first-line means of TRT because of wide fluctuations in testosterone levels and injection site reactions. There are a number of testosterone gel formulations that are commonly used. There are also skin patches, pellets that are injected into the fatty tissue of the buttocks, and a formulation that is placed in the inner cheek or gum. Currently in the works is a long-acting injection.

Men on replacement T need to be followed carefully to ensure that the TRT is effective, adverse effects are minimal, and blood levels are in-range. Periodic digital rectal exams are important to check the prostate for enlargement and irregularities, and, in addition to T levels, other blood tests are obtained including a blood count and PSA (Prostate Specific Antigen).  Potential complications of TRT include acne and oily skin, increased hematocrit (thicker, richer blood), worsening of sleep apnea, hair loss, and suppression of fertility.

Bottom Line: T and E levels are of vital importance to men (as well as women), greatly impacting physical development, sexuality, mood, energy levels, etc. So while T advertisements may be annoying and confusing, it is wise nonetheless to assess and monitor T levels, particularly if one is experiencing any of the myriad of symptoms associated with low T.

Reference: “Gonadal Steroids and Body Composition, Strength, and Sexual Function in Men by Joel Finkelstein, M.D., et al:  ”The New England Journal of Medicine (September 12, 2013)

Andrew Siegel, M.D.

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

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health;  book is in press and will be available in e-book and paperback formats in November 2013.

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Tainted By Testosterone: The Ultimate Double-Edged Sword

August 10, 2013

Andrew Siegel, MD  Blog #115

Many brilliant men have experienced their demise and downfall that can be explained in part— perhaps a large part—by a potent hormone known as testosterone, or more commonly as “T.” Bill Clinton, Elliott Spitzer, Anthony Weiner, John Edwards, Mark Sanford, Arnold Schwarzenegger and San Diego Mayor Bob Filner are all members of the “tainted by testosterone (TBT) club,” who have sustained career derailments partially attributed to the powerful effects of this chemical produced by the testicles and adrenal glands.  Aside from these well-known political celebrities, many a lesser-known man—just your average Joe—has similarly succumbed to the influence of T and joined the TBT club.

The nickname “T” has become very much in vogue these days. Many of my patients come into the office specifically asking for me to check their T levels—thank you, America Pharma.  The pharmaceutical industry is largely responsible for increasing grass-roots awareness of testosterone issues via direct-to-consumer advertising and promotion of testosterone replacement products. Once a subject that was primarily the domain of urologists and endocrinologists, T has gone mainstream.

What exactly is this powerful chemical that can have such a profound influence on a man’s behavior?  Many of us who enjoy the company of canine friends can attest to the dramatic change in behavior of our male pets after they are “fixed” by surgical castration. Man’s best friends become less aggressive, more docile, less alpha male, and less likely to hump your guest’s leg.  The term “fix” seem to imply that something was broken.  Extrapolate to human beings and one can understand how, when our brains are bathed in T, our thoughts, behaviors, and actions are influenced and modulated.

T—manufactured primarily in the testicles although a small percentage is made by the adrenal glands—is an all-important male sex hormone that goes way beyond male sexuality.  T is regarded as a key element in driving and maintaining men’s health. Current evidence suggests that a man’s testosterone level might serve as a very good indicator and marker of general health.  Aside from contributing to libido, masculinity and sexual function, T is responsible for all of the physical changes that occur 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 mood, bone and muscle strength, red blood cell count, energy, and general mojo.

T is nothing short of being a drug with profound psychopharmacological effects. One can appreciate the potency of this powerful chemical simply by observing the physical, emotional, and libidinal changes that result in the transition from “little boy” pre-pubertal status to “big man” post-pubertal status. Not in any way to diminish the role of environmental factors that most certainly play a role, T is the difference between the little boy in the backyard playing with the toy soldier and a water pistol and the little girl on the porch playing with her dolls and jacks.  T is rocket fuel that can make a man all “piss and vinegar.”

T is most certainly a double-edged sword—on the one hand, it is essential for male health and masculinity, but at the same time it can drive our libido to the danger zone in which temptation and opportunity conspire, with potentially perilous results in terms of relationships, careers, lives, etc.  By no means am I implying that this hormone is solely responsible for man’s impulsiveness, improprieties and indiscretions, but it unquestionably plays a significant role.  Assuredly, “It wasn’t me, it was my T” would be an unsatisfactory justification of the behaviors of Clinton, Spitzer, Weiner, Edwards, Sanford, Schwarzenegger and Filner.  However, the role of T cannot be discounted and helps explain the biochemical basis of male behaviors.  If we treated the men of our species similarly to the way in which we treated our male canine pets by “fixing” them (I am not in any way suggesting this), then we most probably would not bear witness to the kind of career-slamming, self-destructive and life-disruptive indiscretions that have been such common occurrences.

Having a low T is clearly not a good thing.  We know this from observing two populations of men—those who have suffered the consequences of low T that has developed coincident with the aging process and those who are put on medications that purposefully lower T, usually for the management of prostate cancer. Most men will have an approximately 1% decline of T each year after age 30; however, this 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; and more. Essentially, low T accelerates the aging process.

So, low T is bad and normal T can influence men to behave badly. Is it possible to find a balance between healthy masculinity and unhealthy philandering and other inappropriate male sexual behaviors?  I sure hope so.  For the record, I don’t really care what politicians do in their free time as long as they do their jobs well. Clearly, they face tremendous stresses and pressures and need outlets for release.  However, it certainly would be nice if they didn’t make such a public spectacle and so embarrass themselves and their families. One has to consider that the very potent chemical T plays a vital role in determining the powerful alpha-male personality that is so fundamental to political ambition and ascent. Unfortunately, it is the very same T that contributes to influencing men to behave badly and stupidly, ending up in sabotaging political intentions and, more importantly, causing their lives to spiral down into a freefall. As borne out by the activities and affairs of many politicians in power, T can be thought of as “fertilizer” for the penis and the very brain that governs and guides that penis.

For some men, T engenders a situation akin to walking around with a loaded shotgun that begs to be unloaded, and the longer it’s been since the weapon has been fired, the greater the need to unload.  T has undoubtedly played a major role and influence in terms of male aggressiveness, violence, homicides, destruction, power struggles, wars, and death that run rampant in our civilization.  Our male gender has been both blessed and cursed by this powerful chemical that is one of the drugs within our internal pharmacy.  The challenge is to use this drug responsibly.

Who Knew?  Many women claim that men think with their “little brains.” All joking aside, there is genuine scientific merit for this insofar as testosterone is a hormone that has many biochemical functions and effects.  Men’s brains are literally bathed in this hormone that can profoundly influence emotions, behavior and thoughts. As a Yiddish proverb from Phillip Roth’s ‘Portnoy’s Complaint’ stated: “Ven der putz shteht, ligt der sechel in drerd,” translated as “when the prick stands up, the brains get buried in the ground.”

Who Knew? The comedian Robin Williams famously said: “God gave every man a brain and a penis, but only enough blood to make one work at a time.”

Who Knew? Too many of us use our penises as our compasses, navigational instruments that give us “direction.”

Who Knew? The athletic “cup” is the device that provides protection to the male genitals for those participating in sports like baseball, hockey, soccer and boxing. The cup was devised years before the first protective helmet for one’s head was used.  This tells you where men’s priorities lie—big head/little head!

 

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

The Who Knew?  quips are from my forthcoming book, Male Pelvic Fitness: Optimizing Sexual and Urinary Health (in press).

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.