Posts Tagged ‘testosterone deficiency’

Testosterone Update 2017: Untangling The Web

January 21, 2017

Andrew Siegel, MD   1/21/17

Testosterone deficiency (TD) is a not uncommon male medical condition marked by characteristic symptoms and physical findings in the face of low levels or low activity of testosterone (T). TD is most often seen in men above the age of 50 years and is a frequent reason for why men make appointments with urologists.


What are the 3 best predictors of TD?

1. Decreased sex drive

2. Erectile dysfunction (ED)

3. Decreased frequency of morning erections

T is a hormone that is essential to male vitality. TD can affect the function of many different organ systems and negatively impact one’s quality of life. Its signs and symptoms can vary greatly. Since T regulates the male sexual response—including desire, arousal, erections, ejaculation and orgasm—sexual dysfunction is a common component of TD and is often the presenting symptom. Low T can give rise to diminished libido, altered penile rigidity, decreased morning and nocturnal erections, decreased ejaculate volume and has been associated with delayed ejaculation. Other common symptoms are decreased energy and vigor, fatigue, muscle weakness, increased body fat, depression and impaired concentration and cognitive ability. Common signs are weight gain, visceral obesity (increased waist circumference), decreased muscle mass and bone density, decreased body and pubic hair, gynecomastia (male breast development) and anemia.

TD is often seen in men with chronic diseases including obesity, diabetes, metabolic syndrome, osteoporosis, HIV infection, opioid drug abuse, and chronic steroid usage.

Why does TD occur?

TD can result from a problem with the ability of the testes to produce T, or alternatively, because of an issue with the hypothalamus or pituitary gland in which there is inadequate production of the hormones that trigger testes production of T. At times there is adequate T, but impairment of T action because of inability of T to bind to the appropriate receptors. Additionally, increased levels of sex hormone binding globulin (SHBG), a molecule that binds T, can result in decreased levels of “available” T despite normal T levels.

Not an Exact Science

It is important to note that not everybody who has a low T level will have characteristic signs and symptoms and also that it is possible to have signs and symptoms of TD with a normal T level.

 Checking for TD should be done under the circumstance of a male complaining of any of the aforementioned symptoms and signs. Shortcomings of measuring T levels are results that can vary from laboratory to laboratory, a lack of a consistent and clinically relevant reference range for T, the variability of T levels depending on time of day that levels are drawn (values are highest in the early morning) and the fact that it is the free T and not the total T (TT) that is “available” to most tissues. T circulates in the blood mainly bound to proteins (SHBG and albumin). It is free T and albumin-bound T that are tissue “available” and active.

If TT and/or free T are low, the levels of the pituitary hormones luteinizing hormone (LH) and prolactin (P) levels should be obtained to distinguish between a pituitary versus a testes issue. Symptomatic men with a TT < 350 are candidates for treatment. A 3-6 month trial of treatment may also be considered in men with symptoms and signs, but without definitive TD on lab testing since there is no absolute T level that will reliably distinguish who will or will not respond to treatment.

T and Prostate Cancer

Although testosterone deprivation has proven effective in treating advanced prostate cancer, there is no evidence to support that treatment of TD with T will increase the risk of prostate cancer. Studies indicate that if T < 250, increasing levels of T will stimulate prostate growth, but once T > 250, a saturation point (threshold) is reached with further increases in T causing little or no additional prostate growth.

T and Cardiac Disease

 A broad review of many articles fails to support the view that T use is associated with cardiovascular risks. In fact, the weight of evidence suggests that treating TD offers cardiovascular benefits.

T and Fertility

T causes impaired sperm production as T is a natural contraception and T replacement should not be used in men desiring to initiate a pregnancy.

TD Treatment

There are numerous different means of T treatment. T pills are not a satisfactory option since testosterone is inactivated in its pass through the liver. There is a buccal formulation that is placed and absorbed between the gum and cheek. There are numerous skin formulations including patches and gels. These skin formulations are commonly used, but are expensive, carry the risk of transference to children, spouses, and pets, and can cause skin irritation. They have the advantage of flexible dosing, easy administration, and immediate decrease in T levels after stopping treatment. Long-acting T pellets can be implanted in the fatty tissue of the buttocks, generally effective for 3 to 4 months or so. The insurance hoops that are required to get this formulation approved and covered have proven to be a major challenge. T injections are also commonly used, typically using a slowly absorbed “depot” injection that, depending on the dosage, can last 1-3 weeks. There is also a very long-acting formulation that, like the T pellets, requires a very taxing process to gain insurance approval.

As an alternative to T replacement, clomiphene citrate is a selective estrogen receptor modulator that when taken on a daily basis will increase both testosterone levels and sperm count by stimulating natural testes production. Human chorionic gonadotropin (hCG) can be used as well. Advantages are that they stimulate natural testosterone production and do not impair sperm count.

Adverse Effects of T Treatment

Careful monitoring is imperative for anybody on T treatment. T levels must be checked in order to assure levels in the proper range. Prostate exams and PSA levels are used to monitor the prostate gland and a periodic blood count is performed to ensure that one’s red blood cell count does not becoming too elevated, which can incur the risk of developing blood clots.

It is important to understand that external T will suppress whatever natural T is being made by the testes, since the body recognizes the T and the testes loses its stimulation to produce both T and sperm. Long term T use can cause atrophy (shrinkage) of the testes.

Ongoing Treatment

Those patients who are experiencing benefits of T treatment can have periodic “holidays” of discontinuation to reassess the continued need for the treatment.

Excellent resource: Diagnosis And Treatment Of Testosterone Deficiency: Recommendations From The Fourth International Consultation For Sexual Medicine, Journal of Sexual Medicine 2016; 13:1787 – 1804

Wishing you the best of health,

2014-04-23 20:16:29

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”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as 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 that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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


TESTOSTERONE: Truths and Tall Tales—25 Questions Answered

October 17, 2015

Andrew Siegel MD   10/17/15


(Thank you, Pixabay, for above image)

There has been an “epidemic” of a clincal syndrome based on low testosterone levels.  Is it real or is it a pharmaceutical company “figment” fueled by aggressive direct-to-consumer marketing for expensive and profitable easy-to-apply testosterone products?  Is testosterone replacement therapy the fast track to youth and alpha-male sexuality for the aging male, or is it harmful?  There is no subject rife with more confusion and misinformation than testosterone deficiency and its treatment. Hopefully, the following 25 questions and answers, culled from those commonly asked by my patients at office visits, will help enlighten and inform you and clarify misconceptions and falsehoods.


T: Testosterone (the key male sex hormone)        TD: Testosterone Deficiency

TRT: Testosterone Replacement Therapy       E: Estrogen (the key female sex hormone)

  1.  I don’t recall hearing much about testosterone years ago–Why has it suddenly become such a hot and trendy topic?

Big Pharma with their deep pockets and oversized advertising budgets started the “T” ball rolling. In 2008, AbbVie—manufacturer of Androgel—began an “Is it low T?” television campaign. Since that time, T has become a household word and T sales are up over 500% in a very competitive several billion-dollar market.

     2.  What exactly is T?

Testosterone is an “anabolic” hormone, a chemical messenger that promotes growth via protein synthesis, which drives the building of muscle and bone mass as well as strength; testosterone is equally an “androgenic” hormone, causing masculinization. T is made from cholesterol with most produced in the testes, with a small amount made in the adrenal glands (organs that sit above kidneys). 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. If you find that you are most amorous in the early morning, now you have a good biochemical explanation.

   3.   When does T kick in and what does it do?

T surges around age 12-14 or so and drives puberty, causing the following: penis enlargement; development of an interest in sex; increased erections; pubic, underarm, 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; sperm production; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and the transition from “cute” baby face to “angular” adult face.

   4.   Is T important after puberty?                                                                                                                                                                                                                                                                                                                                                        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.”

   5.   What is TD and why does it occur?

TD is a clinical and biochemical syndrome characterized by relevant symptoms and signs in conjunction with a deficiency of T or T action. Symptomatic TD occurs in 2-6% of men.  There is approximately a 1% decline in T level each year after age 30. Most commonly it is an impaired testicular production of T. It can also happen because of a pituitary issue in which there is not enough production of luteinizing hormone (LH), the hormone that drives the testes to manufacture T.  Furthermore, it can happen under circumstances of normal T levels when there are elevated levels of the hormone that strongly binds T (SHBG), reducing the amounts of T available for action. It is important to distinguish TD on the basis of testes impairment vs. pituitary impairment, as the management is different.                                                                                                          

   6.   Is T going to help my erections, which are not quite what they used to be?  

Maybe.  Although T is important for sexual function and for maintaining the health and vitality of the penis, one does not need high or even normal levels of T to obtain an erection.  A good example is a pre-pubertal boy who gets erections all the time, but has no interest in sex.  The more compelling role of T is in driving libido.                                                                                                                                                                                                                                                                                                           7.   T seems like such a vital hormone for men…is it for me?                                                                                                                                                                                                                                                                                                               ONLY under the circumstances of a testicular or pituitary problem causing the characteristic symptoms of TD coupled with a blood test that proves that low T levels is it worth pursuing a trial of TRT. It is only beneficial continuing the TRT if it is providing meaningful symptom improvement in the face of a normalized T level.

   8.   How does T get to the body tissues where it works?

Since T is a hormone–a chemical messenger that is made in one locale but works elsewhere–it needs to be transported to get to those cells where it acts.  T circulates in the blood stream–60% is inactive as it is tightly bound to SHBG (sex hormone binding globulin), 38% is weakly bound to albumin, and 2% is free. The albumin-bound and free T are the biologically “active” forms of T.

   9.   How does T work?

Much of T is converted to dihydrotestosterone (DHT), a more potent form, which couples with a special receptor enabling it to move into the nucleus of cells and bind to DNA, where it provides the blueprint for protein synthesis. Some T does so without being converted to DHT and some T is converted to E, the main female hormone.

   10.   What about the female hormone estrogen…is it important for men?

Yes…More than 80% of E in males is derived from T. When levels of T are low, a decline in E levels will occur. E deficiency is important in terms of osteopenia (bone thinning) in men. As commonly happens with abdominal obesity, E levels become too high as abdominal fat is an active endocrine organ that converts T to E, causing low T, high E, breast development, the appearance of a smaller penis and general emasculation.

   11.   Why have T levels been dropping over the years?

Unhealthy lifestyle and the use of alcohol, steroids (for asthma, arthritis, connective tissue disorders and inflammatory bowel diseases) and opiate pain medications (methadone, tramadol, etc.) are risk factors. Obesity has played a huge (pardon the pun) role. Diabetes and metabolic syndrome have contributed to the low T epidemic as well. Physical and psychological stress affect pituitary hormone synthesis, which can give rise to low T levels. Sleep apnea can contribute to TD. Environmental factors such as phthalates, commonly used in plastic products, as well as many other environmental exposures, are associated with low T levels.

   12.   How important of a factor is obesity in causing TD?

Obesity is the single most common cause of TD in the developed world. More than half of men with TD are overweight or obese.  The good news is that it is potentially reversible with weight loss.

   13.  What is the issue with diagnosing low T based upon the established ADAM (androgen deficiency in the aging male) screening test?

The ADAM screening questions are very general and involve decreased libido, diminished erections, lack of energy, decrease in strength/endurance, loss of height, decreased joy, the presence of sadness or grumpiness, deterioration in sports performance, falling asleep after dinner and deterioration in work performance.  These symptoms have an enormous overlap with changes that accompany normal aging, insufficient or poor quality sleep, overworking and/or an unhealthy lifestyle.

Take, for example, a professional athlete of your choice who is at peak performance in his early 20’s. Fast-forward 30 years…how many of the aforementioned questions do you think will be answered positively?… Is it low T?…Possibly, but certainly not probably.

   14.   What are the symptoms that indicate the possibility of TD?

5 domains may be affected by TD: physical, sexual, cognitive, affect and sleep. Physical changes are reduced muscle mass and strength, increased body fat and abnormal lipid profiles, frailty, breast development, loss of body hair and central obesity. Sexual changes include decreased desire, diminished erection quality and weakened ejaculation and orgasm. Cognitive changes that may occur are impaired concentration, diminished verbal memory and altered visual-spatial awareness. Changes in affect can be a reduced sense of general wellbeing, decreased energy and motivation, anxiety, depression and irritability. Sleep issues include fatigue, tendency to sleep during the day and difficulties falling and staying asleep.

   15.   How does one diagnose TD with lab testing?

The diagnosis of TD is made via a blood test for total T and free T as well as for the pituitary hormones, LH and prolactin. In cases of obese or elderly men, SHBG can be useful. It is important to know that T levels can vary depending on the particular lab and can fluctuate on a day-to-day basis as well as depending on what time of day it is drawn, as T has circadian biorhythms.  T can be temporarily suppressed by illness, nutritional deficiency and certain medications. Fasting T levels are generally higher than T levels after a meal. The bottom line is that T should be checked on at least two occasions.

   16.   What is the first-line approach to treating TD?

Lifestyle improvement measures including weight reduction, exercising regularly, management of sleep apnea and stopping the use of opioids.

   17.   When should TRT be used?

When TD fails to respond to first-line approaches in a man with characteristic symptoms and laboratory documentation of TD.

   18.   What is the goal of TRT?

To restore T levels to the mid-normal range of levels observed for healthy men and alleviate the signs and symptoms of TD without causing significant side effects or safety issues.

   19.   What are some of the testicular side effects of TRT?

Because TRT is an external source of T, it suppresses testes function, resulting in diminished sperm count, decreased fertility and the possibility of testes atrophy (shrinkage) with long-term use. Men who wish to retain fertility should not be put on TRT, but should consider the use of an oral medication that stimulates the testes to produce natural testosterone without suppressing sperm count.

   20.    What are some of the other side effects of TRT?

Acne, oily skin, breast development, worsening of sleep apnea, hair loss, fluid retention, elevated blood count and aggression.

   21.   How is TRT administered?

There are many different preparations: buccal (applied to the gums); transdermal (patches and gels); nasal gel; injections; and pellet implants. Each has advantages and disadvantages.

   22.   What about treating TD without TRT?

Since TRT impairs sperm development and fertility and may result in testes atrophy, an alternative to TRT–clomiphene citrate–works by stimulating the testes to produce natural T. It is approved by the FDA for both male and female fertility, but not for TD, so must be prescribed “off-label” for TD.

    23.   Do men with TD on TRT need follow up?

Yes, regular follow up is imperative to ensure that the TRT is effective, adverse effects are minimal, and T 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 important including a blood count to check for increased hematocrit (thicker, richer blood) and PSA (Prostate Specific Antigen).  With the commonly used gel products, absorption rates vary considerably from person to person depending on skin thickness, body hair, preparation, application site, degree of sweating, etc., so dose adjustments need to be made depending on T levels that are periodically checked.

   24.   What about TRT in men with cardiac disease or prostate cancer?

To quote a review article from the Journal of Sexual Medicine (Dean et al: The ISSM’s Process of Care for the Assessment an Management of TD in Adult Men, 2015;12:1660-1686) “TRT use has been complicated by controversies regarding prostate cancer and cardiovascular risks. Although the absence of large-scale, long-term controlled studies with TRT limits the ability to make definitive conclusions regarding these risks, the weight of evidence fails to support either concern.”

    25.   How about T supplements or boosters that can be bought online?

A. The Internet is overrun with male “sexual enhancement” products. They capitalize on male insecurity, which has created a huge market, with hordes of men willing to pay top dollar for products that have misleading claims and are often mislabeled, contaminated and falsely advertised. Unfortunately, such supplements are exempt from the stringent regulatory oversight applied to prescription drugs, which requires reviews of a product’s safety and effectiveness before it goes to market. Do not waste your money!

Bottom Line: TD is very real entity, but not as common as Big Pharma makes it out to be. The symptoms can be devastating and when accompanied by lab testing confirming the suspected clinical diagnosis, TRT can be magical.  I had one patient who eloquently described his “world of black and white turning into a world of color” after his T level was normalized. For many others with the syndrome, the beneficial effects of TRT are far more subtle.  If your T level is normal, it is highly unlikely that your symptoms are on the basis of low T and TRT should not be a consideration.  

Wishing you the best of health,

2014-04-23 20:16:29

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”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

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:

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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Testosterone Replacement Therapy Vs. Performance Enhancing Drugs: A Whole Different Ball Game

March 3, 2012


Recently, an appeals court ruled that Alberto Contador, the three-time winner of the Tour de France, was guilty of “doping,” the use of anabolic steroids to gain an athletic advantage.  This was an additional blow to a sport that has been repeatedly tarnished by doping scandals involving the most elite cyclists in the world.  The court ordered Contador to be stripped of his victory in the 2010 Tour de France as well as twelve subsequent victories.

Doping is by no means unique to cycling, as professional athletes in many different sports—weightlifting, bodybuilding, baseball, football, martial arts, etc.—have tested positive for performance-enhancing substances in the last few years. Doping is banned by all of the major sporting governing bodies.  Not limited to professional athletes, many amateur athletes and bodybuilders have used anabolic steroids to try to improve their game and gain a competitive edge.

Many years before Barry Bonds became involved with doping, it was recognized that the male sex hormone testosterone played a major role in muscle mass and strength.  In the early 1950’s, Soviet Union and other Eastern Bloc Olympic weightlifting teams made use of such androgens, isolated from the testicles of animals, in order to enhance their performance in Olympic events.  Over the subsequent 60 years, the use of synthetic anabolic steroids increased substantially.  Anabolic steroids mimic the effects of testosterone, increasing protein synthesis in cells, causing muscle growth and an increase in lean body mass that results in a gain in muscle strength and thus, a competitive edge.

Anabolic steroids have two different types of effects—anabolic and androgenic.  Anabolic refers to the promotion of cell growth and includes the following effects: increased appetite, increased muscle and bone growth and increased production of red blood cells by the bone marrow, all of which result in increased strength. Androgenic refers to the development of masculine characteristics including oil gland production, libido and sexuality, deep voice and male-pattern hair growth.  Many effects and side effects of anabolic steroids are dose-dependent, in other words, in proportion to the doses used.

Along with the escalating use of synthetic androgens in athletes, there has been a parallel increasing awareness of testosterone deficiency and its treatment, particularly over the last couple of years.  Since testosterone (T) and performance enhancing drugs (PEDs) are both classified as anabolic steroids and each increases muscle mass and strength, they are often incorrectly thought to be one and the same.

T and PEDs differ in structure, biochemistry and use.  The medical use of T is for men with testosterone deficiency, usually manifested by fatigue, diminished sex drive and a constellation of other symptoms.  The goal of treatment is to improve symptoms by getting the testosterone into a normal range.  There are a variety of means of testosterone replacement including gels, creams, trans-dermal patches, pellets and injections.  All of these formulations are FDA approved and provide testosterone that is identical to that of the testosterone that is present in our bodies under normal circumstances.  Testosterone levels are checked periodically to ensure that the testosterone is in the normal range.

PEDs are most often manufactured clandestinely at small labs to avoid FDA scrutiny; they are sometimes obtained through veterinarians, pharmacists or physicians, and are often procured on the black market.  They are intended solely to build muscle mass, strength and improve athletic performance, so their use is beyond the domain of standard medical practice.  PEDs favor anabolic (muscle building) over androgenic (pertaining to the development of male characteristics) effects.

The vast majority of the time, PEDs are provided illicitly by a trainer without special expertise in this area.  The goal is a super-high testosterone level, often ten times or more than normal levels.  Dopers often use the equivalent of 1000 mg or greater of T per week.  PEDs are not the chemical equivalent of T and there is no medical monitoring of users.   Popular PEDs include nandrolone and stanozolol, which were FDA approved years ago, but now have no medical indications.  “Designer” PEDs are often concocted by modifying T; their advantage is that monitoring organizations lack the wherewithal to detect them because of their unique chemical formulations.   The two common patterns of PED usage are stacking and cycling.  Stacking is using two or more PEDs simultaneously whereas cycling is an on—off schedule of use.

PEDs have no medical indications and a risk profile that includes the following: elevated blood pressure; abnormal cholesterol and lipid profiles; altered blood glucose; cardiac muscle enlargement; mood disorders including aggression and violence (“steroid rage”); increased rates of homicide and suicide; liver dysfunction; spontaneous tendon rupture; and endocrine issues including severe and irreversible testicular dysfunction. This contrasts with the use of T, which provides medical benefits and a relatively benign safety profile.  Adverse effects of testosterone may include the following: acne; male breast growth; high red blood cell counts; testicular atrophy; prostate enlargement; decreased sperm production; ankle swelling.

In summary, testosterone deficiency is a genuine problem that can cause a myriad of quality of life as well as quantity of life issues.  When deficiency symptoms are apparent and blood testing confirms the deficiency, testosterone replacement with careful physician monitoring is capable of improving or resolving these issues.  On the other hand, the use of performance enhancing drugs for purposes of achieving anabolic benefits and thus conferring a sports advantage or edge is a very risky business and is not recommended.

Andrew Siegel, M.D.

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

Now available on Amazon Kindle

To view my ten-minute video on testosterone deficiency, go to the following link:

Credit to Dr. Abraham Morgentaler, Harvard Urologist and author of a good little book entitled Testosterone For Life, for providing much of the factual info for this blog.