Posts Tagged ‘testosterone’

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.

t

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

http://www.AndrewSiegelMD.com

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

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 http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

“Girl” At Birth, “Boy” At Puberty… and A Blockbuster Drug

December 17, 2016

Andrew Siegel MD 12/17/16

Last weeks’ entry discussed the similarities and common embryological origin of male and female genitals.  Today’s entry segues into a fascinating genetic defect that causes “ambiguous” genitalia and how Big Pharma capitalized on the positive aspects of this genetic defect and created a billion dollar industry with a type of medication in common usage and, in fact, one that yours truly takes on a daily basis.

Whether one develops a penis or a vagina is determined instantly the moment the father’s sperm penetrates the mother’s egg. The egg contains only an X chromosome and the sperm either an X or Y chromosome. The blueprint for female genital development is when the coupling results in an XX; the blueprint for male genital development when the coupling results in an XY.

Bottom Line: Genetic (chromosomal) sex determines genital sex. The father determines the sex of the child.

Skip ahead to a few weeks later, when the fertilized egg has turned into an embryo. At this time the external genitals are identical…somewhat surprising considering how very different the genitals are in appearance at birth and beyond.

Female genitals are the “default” model, which will remain female, absent the presence of the male hormone testosterone (T). When T is present it is converted into an activated form–dihydrotestosterone (DHT) –which causes conversion of what would be a vulva and vagina into a penis and scrotum. Biochemical magic!

In the young embryo there are three key genital structures: the “tubercle,” the “folds” and the “swellings.”

In the absence of T/DHT, the genital tubercle (a midline swelling) develops into a clitoris. The urogenital folds (two vertically-oriented folds of tissue below the genital tubercle) become  labia minora (inner lips). The labio-scrotal swellings (two vertically-oriented bulges outside the urogenital folds) fuse to become labia majora (outer lips).

In the presence of T/DHT the genital tubercle morphs into a penis, the urogenital folds become the urethra and part of the penile shaft and the labio-scrotal swellings fuse to become a scrotum.

Bottom Line: Female external genitals are the default model. The developing embryo will remain female unless T/DHT are available to masculinize the external genitals. 

“Ambiguous” genitalia

XY chromosomes determine male genital development and XX chromosomes determine female genital development and the vast majority of the time, the external genitals develop as per genetic blueprint with no ambiguity—a penis vs. a clitoris, scrotum vs. labia, etc.

However, the developmental process that causes genital tissue to become “male” or “female” can be disrupted and may lead to “ambiguous” genitals. These disruptions can cause the external genitals to not have a typical male or female appearance, making it difficult to identify an infant as male or female. Rarely, the appearance may be the complete opposite of the genetic sex (XX or XY).

The ambiguous genitals of a genetic female have the following characteristics: a clitoris that is substantially enlarged and can look like a small penis; the urethral opening in an abnormal location; and fused labia that appear like a scrotum. The situation can be so extreme that the infant is thought to be a newborn male with undescended testicles.

By far, the most common cause of XX appearing males is a condition of the adrenal gland that affects the production of hormones ultimately resulting in a genetic female having high levels of T.  These high levels “masculinize” the female default model.

The ambiguous genitals of a genetic male have the following characteristics: a small penis resembling an enlarged clitoris; an abnormal location for the urethral opening, sometimes opening on the perineum and not the penis; a small scrotum that may be separated in the midline appearing as labia; and undescended testicles.

XY appearing females can occur because of lack of production of T, lack of T receptors such that the body cannot respond to T, or the presence of T but lack of the enzyme that converts T to DHT (more on this below).

The Guevedoces

In the early 1970s, a Cornell endocrinologist (hormone specialist) conducted an expedition to the Dominican Republic to investigate reports of children who were thought to be “girls” at birth who turned into “boys” at puberty.  These biological males with normal male chromosomal make-up (XY) are born with female-appearing genitals and shockingly develop male genital anatomy at the time of puberty. These children were called guevedoces (“penis at 12 years”).

In this isolated village, 2% of births in the 1970s were guevedoces.  These children who appeared to be girls at birth developed a penis, testicles and typical male physical characteristics at the time of puberty. Most guevedoces were found to be descendants of a single common ancestor. The problem was shown to be deficiency of an enzyme known as 5-alpha reductase (5AR), responsible for converting T into  DHT, the more potent activated form of T. During embryonic development, DHT is essential for the development of normal male external genitals.  In the absence of DHT, the external genitals develop as female.

Internally the guevedoces have male gonadal tissue (testes and not ovaries). The external genitals are feminized, with a short “vagina,” undescended testicles and an absent uterus. With the testosterone surge at puberty, the tiny penis–- that was thought to be a clitoris–-develops into a normal-size, functional penis; at the same time, the testicles, previously not within the scrotal sac, descend into the scrotum, and other typical male characteristics develop including sex drive, body musculature, voice change, etc.  For the duration of their lives, the guevedoces resemble other Dominican men in all respects except that they have scanty beard growth and never develop acne, prostate gland enlargement or baldness.

guevedoces-bbc-republica-dominicana

A male with 5AR deficiency at age 12, 19 and 42

The discovery of this congenital 5-alpha reductase (5AR) deficiency in this small enclave of the Dominican Republic enabled an effective drug treatment for prostate enlargement. In the 1970s a drug was developed that replicated the effects that the 5AR deficiency had on the adult guevedoces population. Scientists reasoned that if 5AR could be inhibited after the external genitalia were fully formed and mature, then a medication to shrink the prostate, relieve urinary symptoms and treat baldness and acne might be developed.

The legacy of the guevedoces became a class of drugs known as 5AR inhibitors (5ARIs), the “prostate pills.”  Finasteride (Proscar for the prostate; Propecia for male pattern baldness), the original 5ARI, was approved in 1992. Dutasteride (Avodart) followed, and the treatment approach to prostatic obstruction was forevermore changed. Aside from prostate shrinkage and symptomatic relief of urinary symptoms, this class of drugs is an effective treatment for male pattern baldness.

Wishing you the best of health,

2014-04-23 20:16:29

www.AndrewSiegelMD.com

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

Andrew Siegel MD practices in Maywood, NJ.  He is board-certified in both urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey.

Dr. Siegel is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health (www.TheKegelFix.com) and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health (www.MalePelvicFitness.com). 

 

“Doc, My Penis Is Shrinking”

October 8, 2016

Andrew Siegel MD  10/8/16

cuixes_de_lapol%c2%b7lo_de_pinedo

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 (http://creativecommons.org/licenses/by-sa/3.0)%5D, 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:

https://healthdoc13.wordpress.com/2015/05/23/peyronies-disease-not-the-kind-of-curve-you-want/

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.

vsd

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

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 http://www.MalePelvicFitness.com
  • “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

http://www.AndrewSiegelMD.com

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 & Urinary Health http://www.MalePelvicFitness.com

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

http://www.TheKegelFix.com

E-book available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback available via websites. Author page on Amazon:

http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix

https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx, Vacuum Suction Devices and many other quality products can be obtained at http://www.UrologyHealthStore.com. Use promo code “UROLOGY10” at checkout for 10% discount. 

How To Raise Your Testosterone, Naturally

September 3, 2016

Andrew Siegel MD  9/3/2016

17373-men-and-women-performing-aerobic-exercises-pv

(CDC/Amanda Mills from Public Health Image Library)

Two weeks ago, my entry was about the medication Clomid–a nice alternative to testosterone replacement therapy. What about a non-pharmacological, natural approach to raising testosterone levels?

Testosterone (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.”

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.  Low 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.

Lifestyle factors are strongly associated with variations in testosterone (T) levels, with healthy lifestyles correlating with higher levels of T and unhealthy lifestyles with lower levels.  Some physicians regard T level as a laboratory marker of male physical health.

One of the key factors responsible for some of the decline in T that accompanies aging is excessive body fat. In fact, there is an inverse relationship between obesity and T levels, with increased body mass index (BMI) correlating with decreased T.

Factoid: Every 5-point increase in BMI translates to a 10% dip in T–an equivalent decline as would typically occur with 10 years of aging.

Fatty tissue – particularly visceral abdominal fat (the “beer belly”) – contains an abundance of metabolically active factors and hormones including aromatase, an enzyme which functions to convert T to the female sex hormone estrogen. Men with large bellies consequently are often found to have lower T levels and higher estrogen levels, which can result in “emasculation” with loss of sex drive, diminished erections, the disturbing loss of penile length and the presence of gynecomastia (man boobs)

Factoid: In addition to the decline in T, for every 35 lb. weight gain there is a 1-inch loss in apparent penile length because of the pubic fat pad that hides the penis.  

The good news is that weight loss will increase T levels and is capable of improving all of the aforementioned signs and symptoms. This has been demonstrated with all means of  weight loss, ranging from caloric restriction to bariatric surgery.

Another important lifestyle factor associated with variations in T levels is the extent of one’s physical fitness. Exercise is clearly associated with higher T levels. The degree of potential increase in T is related to both the quantity and quality of exercise. In general, the more time invested in moderate intensity exercise, the greater the increase in T.  As important as aerobic exercise is for health, resistance exercise is superior in terms of increasing T.

Bottom Line:  To optimize your T level, maintain a healthy weight and engage in an exercise program emphasizing resistance training.  If you are obese and sedentary, it is likely that you have low T, a situation that can be reversed with a modification to a healthier lifestyle. 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Clomid: Not Just For The Ladies

August 20, 2016

Andrew Siegel MD 8/20/2016

Gender_differences_male_female

Frank Palopoli, Father Of Fertility

Frank Palopoli, the chemist who developed Clomid (clomiphene citrate), died last week at age 94. He conceived (pun intended) Clomid in the 1950s, a medication that stimulates ovulation and became the most widely prescribed fertility drug for women, resulting in pregnancy in millions of women who otherwise would not have been able to do so. Approximately 80% of women whose fertility is due to failure of ovulation respond to Clomid enabling conception. Clomid works by increasing production of hormones that spur egg ripening and release.

What’s Good For The Goose Is Good For The Gander

Clomid is not just for the ladies! In urology we have used it for many years to stimulate sperm production in infertile men with low sperm counts. But here is a little secret: it also raises testosterone levels nicely. It does so by stimulating the testes to secrete natural testosterone, as opposed to the other testosterone replacement products on the market that are external sources of testosterone that actually shut down testes production of sperm and testosterone. No shrunken testicles that have their function turned off, but respectable family jewels, happily churning out sperm and testosterone, as nature intended.

Clomid Biochemistry In A Nutshell (no pun intended!)

Clomid is a selective estrogen receptor modulator (SERM). It works by increasing levels of the pituitary hormones that trigger the ovaries to produce eggs and the testes to produce sperm and testosterone. It blocks estrogen at the pituitary, so the pituitary sees less estrogen and makes more LH (luteinizing hormone) that stimulates the testes to make testosterone, and more FSH (follicle stimulating hormone) that stimulates the testes to make sperm. This is as opposed to external testosterone, which does the opposite, increasing estrogen levels that prompt the pituitary to make less LH and FSH, which causes the testes to cease production of sperm and testosterone.

Clomid usually works like a charm in increasing testosterone 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 people): flushes, abdominal discomfort, nausea and vomiting, headache, and rarely visual symptoms.

 One issue is that Clomid is not FDA approved for low testosterone, only for infertility. Many physicians are reluctant to use a medication that is not FDA approved for a specific purpose, requiring it to be used “off label.” However, Clomid is effective and less expensive than most of the other overpriced testosterone products on the market and has the major advantage of stimulating natural testosterone while not shutting down testicular function.

Bottom Line: By virtue of a very sophisticated biofeedback system involving the pituitary gland in the brain and the testes, the use of external testosterone to boost native testosterone results in whatever feeble function the testes might have had to virtually cease completely and the possibility of atrophied, non-functional testes that no longer produce any sperm or testosterone.

 Clomid is an oral, less expensive alternative to testosterone replacement that stimulates natural testosterone production as well as sperm production. Kudos to Dr. Palopoli, whose magic drug has not only helped millions of women get pregnant, but has also helped enable countless men to fertilize their partners as well as raise their testosterone levels. Clomid is safer and much more sensible than traditional testosterone replacement.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Eating Yourself Limp

January 2, 2016

Andrew Siegel MD   1/2/16

Central_Obesity_008.jpg

Today’s entry is on the topic of how overeating and obesity affect one’s manhood and vitality (this holds true for female sexual function as well).  While optimal sexual function is based on many factors, it is important to recognize that our food choices play a definite role. What we eat—or don’t eat—impacts our sex lives.  It’s a new  year– a fresh start–and time for many resolutions, which often involve weight loss and a healthier lifestyle.  Yet another benefit of becoming leaner and fitter is improved sexual function. 

Sexuality is an important part of our human existence. Healthy sexual function involves a good libido, the ability to obtain and maintain a rigid erection and the ability to ejaculate and experience a climax. Although not a necessity for a healthy life, diminished sexual function can result in loss of self-esteem, embarrassment, a sense of isolation and frustration and even depression.

Sexual functioning is complicated and dependent upon a number of systems working in tandem– the endocrine system (which produces hormones); the central and peripheral nervous systems (which provide nerve control); the vascular system (which conducts blood flow); and the musculo-skeletal system (specifically the pelvic floor muscles that help maintain the high blood pressures in the penis necessary for erectile rigidity).

Sexual function is a good indicator of underlying cardiovascular health. A healthy sexual response is largely about blood flow to the genital and pelvic area. The penis is a marvel of engineering, uniquely capable of increasing its blood flow by a factor of 40-50 times over baseline, this surge happening within seconds and responsible for the remarkable physical transition from flaccid to erect. This is accomplished by relaxation of the smooth muscle within the penile arteries and erectile tissues. Pelvic muscle engagement and contraction help prevent the exit of blood from the penis, enhancing penile rigidity and creating penile blood pressures that far exceed normal blood pressure in arteries. For good reason, Gray’s Anatomy textbook over 100 years ago referred to one of the key pelvic floor muscle as the “erector penis.”

Blood flow to the penis is analogous to air pressure within a tire: if there is insufficient pressure, the tire will not properly inflate and will function sub-optimally; at the extreme the tire may be completely flat. Furthermore, slow leaks (that often occur with aging and failure of the smooth muscle within the penile arteries and erectile tissues to relax) promote poor function.

Just as your car suffers a decline in performance if it is dragging around too much of a load, so you penis will function sub-optimally if you are carrying excessive weight. Obesity steals your manhood and reduces male hormone levels. Abdominal fat converts the male hormone testosterone to the female hormone estrogen. Obese men are more likely to have fatty plaque deposits that clog blood vessels–including the arteries to the penis–making it more difficult to obtain and maintain good-quality erections. Additionally, as your belly gets bigger, your penis appears smaller, lost in the protuberant roundness of your large midriff and the abundant pubic fat pad.

Remember the days when you could achieve a rock-hard erection—majestically pointing upwards—simply by seeing an attractive woman or thinking some vague sexual thought? Chances were that you were young, active, and had an abdomen that somewhat resembled a six-pack. Perhaps now it takes a great deal of physical stimulation to achieve an erection that is barely firm enough to be able to penetrate. Maybe penetration is more of a “shove” than a ready, noble, and natural access. Maybe you need pharmacological assistance to make it possible.

If this is the case, it is probable that you are carrying extra pounds, have a soft belly, and are not physically active. When you’re soft in the middle, you will probably be soft where it counts.  A flaccid penis is entirely consistent with a flaccid body and a hard penis is congruous with a hard body. If your is penis difficult to find, if you have noticed man-boob development, and your libido and erections are not up to par, it may be time to rethink your lifestyle habits.

Healthy lifestyle choices are of paramount importance towards achieving an optimal quality and quantity of life. It should come as no surprise that the initial approach to managing sexual issues is to improve lifestyle choices. These include proper eating habits, maintaining a healthy weight, engaging in exercise, adequate sleep, alcohol in moderation, avoiding tobacco and minimizing stress.

Eating properly is incredibly important, obviously in conjunction with other smart lifestyle choices. Maintaining a healthy weight and fueling up with wholesome and natural and real foods will help prevent weight gain and the build-up of harmful plaque deposits within blood vessels. Healthy fuel includes vegetables, fruits, legumes, nuts, whole grains and fish. Animal products—including lean meats and dairy—should be eaten in moderation. The Mediterranean-style diet is an excellent one for minimizing both sexual dysfunction and heart disease. Poor dietary choices with meals full of calorie-laden, nutritionally-empty selections (e.g., fast food, processed foods, excessive sugars or refined anything), puts one on the fast tract to obesity and clogged arteries that can make your sexual function as small as your belly is big.

Bottom Line: If you want a “sexier” lifestyle, start with a “sexier” style of eating that will improve your overall health and make you feel better, look better and enhance your sexual function.  Smart nutritional choices are a key component of sexual fitness. If you are carrying the burden of too many pounds, now is the perfect time to start on the pathway towards better health and reversing the sexual dysfunction that has been brought on by poor lifestyle choices. 

Wishing you a healthy, peaceful, happy (and sexy) 2016,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. Coming soon is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Author of Promiscuous Eating: Ending Our Self-Destructive Relationship With Food: http://www.PromiscuousEating.com

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: www.PrivateGym.com or Amazon.

TESTOSTERONE: Truths and Tall Tales—25 Questions Answered

October 17, 2015

Andrew Siegel MD   10/17/15

bodybuilding-311351_1280

(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.

Abbreviations:

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

http://www.AndrewSiegelMD.com

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: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. 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: www.PrivateGym.com or Amazon.

Her Breasts and His Prostate…So Similar, So Mysterious

July 18, 2015

Andrew Siegel MD  7/18/15

prostate breast

(Thank you, Wikimedia, for above image)

The female breasts and the male prostate are both sources of fascination, curiosity, and fear. Hidden deep in the pelvis at the crossroads of the male urinary and reproductive systems, the prostate is arguably man’s center of gravity. On the other hand, the breasts—with an equal aura of mystery and power—are situated in the chest superficial to the pectorals, contributing to the alluring female form and allowing ready access for the hungry infant, curiously an erogenous zone as well as a feeding zone.

Interestingly enough, the breasts and prostate share much in common, both serving important “nutritional” roles. Each functions to manufacture a milky fluid; in the case of the breasts, the milk serving as nourishment for infants and in the case of the prostate, the “milk” serving as sustenance for sperm cells, which demand intense nutrition to support their arduous  marathon journey traversing the female reproductive tract.

Breasts are composed of glandular tissue that produces milk, and ducts that transport the milk to the nipple. The remainder of the breast consists of fatty tissue. The glandular tissue is sustained by the female sex hormone estrogen and after menopause when estrogen levels decline, the glandular tissue withers, with the fatty tissue predominating.

The prostate—on the other hand—is made up of glandular tissue that produces prostate “milk,” and ducts that empty this fluid into the urethra at the time of sexual climax. At ejaculation the prostate fluid combines with other reproductive secretions and sperm to form semen. The remainder of the prostate consists of fibro-muscular tissue. The glandular tissue is sustained by the male sex hormone testosterone and after age 40 there is a slow and gradual increase in the size of the prostate gland because of glandular and fibro-muscular cell growth.

Access to the breasts as mammary feeding zones is via stimulation of the erect nipples through the act of nursing. Access to the prostate fluid is via stimulation of the erect penis, with the release of semen and its prostate fluid component at the time of ejaculation.

Both the breasts and prostate can be considered to be reproductive organs since they are vital to nourishing infants and sperm, respectively. At the same time, they are sexual organs. The breasts can be thought of as accessories with a dual role that not only provide milk to infants, but also function as erogenous zones that attract the interest of the opposite sex and contribute positively to the sexual and thus, reproductive process. Similarly, the prostate is both a reproductive and sexual organ, since sexual stimulation resulting in climax is the means of accessing the prostate’s reproductive function.

Both the breasts and prostate are susceptible to similar disease processes including infection, inflammation and cancer. Congestion of the breast and prostate glands can result in a painful mastitis and prostatitis, respectively. Excluding skin cancer, prostate cancer is the most common cancer in men (accounting for 26% of newly diagnosed cancers with men having a 1 in 7 lifetime risk) and breast cancer is the most common cancer in women (accounting for 29% of newly diagnosed cancers with women having a 1 in 8 lifetime risk). Both breast and prostate tissue are dependent upon the sex hormones estrogen and testosterone, respectively, and one mode of treatment for both breast cancer and prostate cancer is suppression of these hormones with medication, e.g., Tamoxifen and Lupron, respectively. Both breast and prostate cancer incidence increase with aging. The median age of breast cancer at diagnosis is the early 60’s and there are 232,000 new cases per year, 40,000 deaths (the second most common form of cancer death, after lung cancer) and there about 3 million breast cancer survivors in the USA. The median age of prostate cancer at diagnosis is the mid 60’s and there are 221,000 new cases per year, 27,500 deaths (the second most common form of cancer death, after lung cancer) and there are about 2.5 million prostate cancer survivors in the USA.

Both breast and prostate cancer are often detected during a screening examination before symptoms have developed. Breast cancer is often picked up via mammography, whereas prostate cancer is often identified via an elevated or accelerated PSA (Prostate Specific Antigen) blood test. Alternatively, breast and prostate cancer are detected when an abnormal lump is found on breast exam or digital rectal exam of the prostate, respectively.

Both breast and prostate cells may develop a non-invasive form of cancer known as carcinoma in situ—ductal carcinoma-in-situ (DCIS) and high grade prostate intraepithelial neoplasia (HGPIN), respectively—non-invasive forms in which the abnormal cells have not grown beyond the layer of cells where they originated, often predating invasive cancer by years.

Family history is relevant with both breast and prostate cancer since there can be a genetic predisposition to both types and having a first degree relative with the disease will typically increase one’s risk. Imaging tests used in the diagnosis and evaluation of both breast and prostate cancers are similar with both ultrasonography and MRI being very useful. Treatment modalities for both breast and prostate cancer share much in common with important roles for surgery, radiation, chemotherapy and hormone therapy.

In a further twist to the relationship between breast and prostate cancer, a recent study showed that women with close male relatives with prostate cancer are more likely to be diagnosed with breast cancer. Compared to women with no family history of breast or prostate cancer, those with a family history of both were 80% more likely to develop breast cancer.

Breast and Prostate Cancer Myths and Facts

“Only old people get breast or prostate cancer.

Fact: 25% of women with breast cancer develop it before age 50, whereas less than 5% of men with prostate cancer develop it before age 50; however, many men in their 50s are diagnosed with the disease.

“Men can’t get breast cancer and women can’t get prostate cancer.”

Fact: 1700 men are diagnosed with breast cancer with 450 deaths on an annual basis.  Women have structures called the Skene’s glands, which are the female homologue of the male prostate gland. On very rare occasions, the female “prostate” can develop cancer. The Skene’s glands are thought to contribute to “female ejaculation” at the time of sexual climax. 

“All lumps in the breast or prostate are cancer.”

Fact: 80% of breast lumps are due to benign conditions as are 50-80% of prostate “nodules.”  If an abnormality is found, further evaluation is necessary.  

“It’s not worth getting screened for breast cancer because of the USPSTF (United States Preventive Services Task Force) recommendation against routine screening mammography in women aged 40 to 49 years and against clinicians teaching women how to perform breast self-examination.  It’s not worth getting screened for prostate cancer because the USPSTF also recommended against prostate-specific antigen (PSA)-based screening for prostate cancer.”

Fact: In my opinion, the USPSTF has done a great deal of harm to public health in the USA with their recommendations. The goal of screening is to pick up cancers in their earliest stages at times when treatment is likely to be most effective. Not all cancers need to be treated and the treatment can differ quite a bit based upon specifics, but screening populations at risk is a no-brainer.  For breast cancer and prostate cancer–the most common cancer in each gender–it is important to screen aggressively to obtain the necessary information to enable doctors and their patients make sensible decisions, which are individualized and nuanced, depending on a number of factors.

The reader is referred to a terrific recent article in the NY Times concerning screening for prostate cancer: http://www.nytimes.com/2015/07/06/opinion/bring-back-prostate-screening.html

Wishing you the best of health,

2014-04-23 20:16:29

AndrewSiegelMD.com

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

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: http://www.MalePelvicFitness.com.  Work in progress is The Kegel Fix: Recharging Female Sexual, Urinary and Pelvic Health.

Co-creator of Private Gym pelvic floor muscle training program for men: http://www.privategym.com—also available on Amazon.

The Private Gym program is the go-to means of achieving pelvic floor muscle strength, tone, power, and endurance. It is a comprehensive, interactive, easy-to-use, medically sanctioned and FDA registered follow-along exercise program that builds upon the foundational work of Dr. Arnold Kegel. It is also the first program designed specifically to teach men how to perform the exercises and a clinical trial has demonstrated its effectiveness in fostering more rigid and durable erections, improved ejaculatory control and heightened orgasms.

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

Man’s Motivation for Medical Ministration: His Penis

October 18, 2014

Andrew Siegel MD

 

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You—as a man—are a master of denial, who, through a combination of nature and nurture, often play the stoic, tough guy, independent, cool as a cucumber, stubborn, non-demonstrative, too-proud-to-ask-directions act. You typically serve the role of provider, protector, hunter, and warrior as opposed to your nurturing and more emotional female gender mate. Furthermore, you are literally “tainted” by testosterone levels that can biochemically impair your ability to think rationally. Truth is that deep inside, most men are actually weak-kneed milquetoasts who are put to shame by women when it comes to true bravado. Regarding seeking help in the form of medical care, men are much more reluctant to do so than women, particularly preventive health care, and medical care is often not sought until after a problem develops, establishes itself and worsens.

Men’s Health: Facts

  • Men live 6 years less than women on average
  • 36% of men seek medical care only when they become really ill
  • 30% of men defer seeking medical help as long as they can
  • 90 million men have a usual place of medical care, as opposed to 106 million women
  • 30 million men reported no office visits with a physician in the past year, as opposed to 16 million women
  • Men have higher rates of inactivity, poor nutrition, and excessive alcohol consumption than women
  • More than 50% of premature death in men in the USA are result of chronic, but preventable medical conditions

One of the challenges of being a physician is to persuade men to pursue preventive health services. Over the years, however, getting the male patient into the office has actually become much easier, thanks to the emerging field of sexual medicine, the availability of Viagra and other ED drugs, and Big Pharma’s extensive direct-to-consumer advertising.

Viagra was the initial drug in its class that addressed a previously unmet medical need with the collateral effect of being the “carrot” that enticed men to see their doctor. The direct-to-consumer advertising effort has resulted in a change in name of the pejorative term “impotence” into the more euphemistic term “erectile dysfunction,” de-stigmatizing sexual dysfunction, resulting in patients more readily making appointments. Big Pharma has also made the word “testosterone,” previously the domain of endocrinologists and urologists, into a commonly used household word, and numerous patients now appear in the office requesting to know what their “T” is.

Men may be stoic when it comes to their general health but when it comes to their genital health it is a different story. To many, their penis is literally their GPS, and when its function goes south, they become immediately motivated to find medical help! Never mind that they are having chest pain that gets dismissed as indigestion—an episode or two of failure to launch an erection is all it takes for an “emergency” appointment! There is some real truth to the concept that men think with their penises.

What most men do not realize is that they actually have a “canary in their trousers,” analogous to the “canary in the coal mine” carried by mine workers into the mines, the death of which would indicate the presence of dangerous gases. Since the penile arteries are generally rather small (diameter of 1 to 2 millimeters) and the coronary (heart) arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the tiny penile arteries, it may soon affect the larger coronary arteries as well—if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.” 

In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson expanded the initials ED to mean: Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries); Early Detection (of cardiovascular disease); and Early Death (if missed).

Bottom Line: Because many men have an “obsession”—if not a “fascination,” with their penises—a dysfunction in this department is often the motivating factor that drives them to seek medical help, which often uncovers other medical issues. The pharmaceutical companies have developed excellent medications to treat ED and are credited with the name “ED” and for de-stigmatizing sexual issues are also responsible for getting the stoic gender into the physician’s office. So man’s peno-centric focus and Big Pharma are actually beneficial for men’s health.

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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

Private Gym: http://www.PrivateGym.com