Testosterone replacement for men
Dr. Monica Carezani Gavin has been providing testosterone replacement therapy for men for the past 10 years at Azani Medical Spa in Bethlehem, Pennsylvania. My patients come with symptoms of fatigue, poor libido, inability to do work outs as before, and mood issues, among many others. With the patient history, symptoms, and laboratory (blood or saliva) data for their hormones levels, we put together a plan for overall hormone replacement. We monitor the results, and adjust as necessary. The hormone replacement can be done with pills, creams, and intramuscular weekly injections at home, depending on needs and patient preference.
Androgen deficiency in the aging male, ADAM for short, is also known as andropause, affects about 1 in 200 men. As men grow older, levels of free testosterone decrease and estrogen levels increase, leading to a many symptoms, including:
Low libido, erectile dysfunction, decreased muscle mass, weight gain, depression, reduced cognitive function, osteoporosis, and declining cardiovascular health.
Men age 50 or older with symptoms of hypogonadism and a total testosterone level < 300ng/dl respond well when started on hormone replacement. A man may be considered hypogonadal at any age if blood tests reveal a total testosterone is less than 200 ng/dl, or bioavailable testosterone is less than 60 ng/dl. Of course each patient is different, and “normal” level for each patient varies.
Advances in understanding the function of hormones and the role of hormone replacement has made it possible to manage many of the negative side-effects associated with age-related hormone decline. Biologically identical testosterone, derived from yams, has the same molecular structure and produces the same effects as the free form of testosterone produced by the testes. The term “testosterone” is often used generically when referring to numerous synthetic derivatives, as well as natural bio-identical testosterone.
Conflicting data in the medical literature about the benefits and risks of testosterone therapy is confusing for medical professionals and patients. It is important to carefully review studies to determine the form of testosterone used. Natural testosterone must not be confused with synthetic derivatives or “anabolic steroids,” which, when used by athletes and bodybuilders, have caused disastrous effects.
For example, administration of synthetic non-aromatizable androgens, like stanozolol or methyltestosterone, causes profound decreases in HDL-C (“good cholesterol”) and significant increases in LDL-C (“bad cholesterol”). Yet, hormone replacement with aromatizable androgens, such as testosterone, results in lower total and LDL cholesterol levels, while having little to no impact on HDL cholesterol levels.
Goals of Testosterone Replacement Therapy in Adult Hypogonadal Men
Improvement in psychological well-being and mood, erectile dysfunction, libido, increased muscle mass, increased strength, preservation of bone mass, and potential decrease in cardiovascular risk.
Testosterone therapy and dosages for men are based on hormone test results. No two individuals are the same and hormonal needs differ from person to person. There are many commercial products available promising to help overcome the negative effects of a testosterone decline (such as loss of libido, depression, and osteoporosis). However, bioidentical testosterone replacement addresses the underlying cause of the problem and not just the side-effects, while offering added long-term health benefits.
Testosterone is a hormone that is important for the male body. It regulates sex drive, maintains bone mass, and helps facilitate the production of red blood cells. As men age, levels of testosterone decline. Between the ages of 30 and 40, testosterone levels in men can start to decrease by as much as one percent every year. When men reach the age of 50, testosterone levels can get very low (referred to as hypogonadism or low-testosterone), triggering a wide range of symptoms, including erectile dysfunction and fatigue.
Testosterone replacement therapy (TRT) is a type of hormone replacement therapy that aims to increase testosterone levels in the body and treat symptoms of low-t in men. TRT can be administered in many forms, including injections, skin patches, or even as a pill. TRT can help men who are losing testosterone due to aging.
Treating Mood Disorders
Studies have shown that men with lower levels of testosterone are more likely to develop depression compared to men with higher testosterone levels. An analysis of 27 research studies that, in total, included more than 1,800 men shows that testosterone treatments can help reduce depressive symptoms in men. A separate study discovered that testosterone increases the number of proteins that transport serotonin throughout the brain. Serotonin is an important chemical in the body that helps regulate mood, and low serotonin levels have been linked to depression.
Recovering Bone and Muscle Mass
Men with low testosterone are more likely to gain weight, which can lead to serious health conditions, like diabetes and heart disease. In addition to weight gain, low testosterone can also cause men to lose muscle and bone mass, increasing their risk of osteoporosis and fractures.
A study shows that testosterone therapy can help men 65 years and older increase bone mass and bone strength after one year of treatment with testosterone gel. The results of this study give researchers hope that testosterone may also be able to reduce the risk of fractures, but long-term studies and more research are needed to determine this.
Improving Memory and Cognitive Function
Low testosterone levels are associated with impaired memory. One study compared the working memory ability of men with normal testosterone levels and men with extremely low testosterone levels (caused by testosterone deprivation therapy (TDT) for the treatment of prostate cancer). Men who had undergone TDT experienced memory loss at a faster rate than men with normal testosterone levels.
Testosterone therapy has been found to help improve spatial memory (orientation) and verbal memory (remembering words and information that are said out loud) in men with low testosterone. The amount of testosterone administered to patients may play a role in testosterone’s ability to improve memory.
Is Testosterone Replacement Therapy Right for You?
Testosterone treatment offers both benefits and risks to men. If you’re interested in learning more about testosterone therapy and whether it is right for you, talk to Dr. Gavin at Azani Medical Spa in Bethlehem. Signs and symptoms of aging may occur for reasons other than low testosterone. Dr. Gavin will perform and evaluation and will test your testosterone levels to determine if you may be a candidate for TRT. We offer Telehealth visits, so the process is easy and simple. You can even collect your saliva specimen from the comfort of your own home and mail it to the lab to have your hormones level tested.
Dr. Gavin treats a lot of men with hypogonadism or low testosterone. There are many different ways to treat low testosterone, with testosterone itself, other medicines that stimulate testosterone, or combinations of medicines. Most men with clearly low testosterone should get on testosterone, and Dr. Gavin finds that injectable testosterone usually works better than testosterone gels or creams or patches. Patches or gels usually do not achieve high enough levels and might be okay for an older person who just wants testosterone a little bit higher, but a younger person often needs the higher levels achieved by injections.
It was traditionally recommended that testosterone injections be given intramuscularly using a big needle, into a muscle, such as the buttocks or shoulder. This is often quite painful and is difficult for the patient to do himself. Dr. Gavin and some other endocrinologists have realized that testosterone can be given subcutaneously, in the stomach, with a small needle that is just as effective as the bigger needle. Patients are given testosterone at a dose of 50 mg to 200 mg once a week to do their injections. Dr. Gavin also recommends 2 syringes with interchangeable needles. One is a larger needle such as a 21-gauge, 1-inch needle to draw up the testosterone and then a smaller one, which would be a 25-gauge, 5/8-inch needle, to inject testosterone in the stomach. The size of the syringe can be either 1 mL or 3 mL, but it is important to have needles that come off and can be replaced.
For patients who are on testosterone and experience testicular shrinkage, Dr. Gavin recommends subcutaneous human chorionic gonadotropin (hCG) injections which help restore their testicular size. hCG is also a good option instead of testosterone if the patient is trying to conceive. Dr. Gavin usually does not give hCG alone, however, because it does not give high enough testosterone levels by itself. However, it works quite well at a dose of 250 to 1000 units subcutaneously 3 times a week in combination with the subcutaneous injection of testosterone.
Patients who are getting testosterone injections can get a high estradiol which leads to breast enlargement and also breast tenderness. Dr. Gavin measures the estradiol after starting a person on testosterone and if the estradiol is high, she adds a medicine called Arimidex which blocks the conversion of testosterone to estradiol. The dose is usually 1 mg pills from 3 to 7 days per week and makes sure the estradiol comes down.
Testosterone gets converted to dihydrotestosterone (DHT) which if high, can lead to prostate growth and/or hair loss. If that happens and DHT is above the normal range, Dr. Gavin prescribes finasteride to block the conversion of testosterone to DHT. Finasteride comes as a more expensive 1 mg pill or less expensive 5 mg pill. Dr. Gavin usually prescribes the 5 mg pill, and the patient can take 1/2 pill of that twice or 3 times a week. He would monitor the DHT levels.
Dr. Gavin monitors CBC and PSA during testosterone replacement. If the PSA goes up the patient needs an evaluation by an urologist. The testosterone dose might need to be reduced or the patient can go on finasteride which helps decrease the conversion to DHT in conjunction with the PSA. If the PSA is quite high, testosterone might need to be discontinued until full evaluation done by urologist.
Patients on testosterone can also get a high hematocrit which can lead, if left high, to blood clots and strokes. A hematocrit above 51% is concerning, but rare. This can be easily monitored. The best remedy for this is for the patient to donate blood to the Red Cross. There are no restrictions on blood donation if the patient is on testosterone, and this is accomplishing a good deed for society and also helping the patient’s health.
Besides testosterone replacement, Dr. Gavin also looks into replacement of other hormones like progesterone, DHEA, and pregnenolone.
Progesterone serves as the precursor to the adrenal hormones cortisol and cortisone, as well as the androgens androstenedione and testosterone. Progesterone deficiency is often accompanied by decreased levels of cortisol and androgens.
Progesterone keeps aldosterone in check by partially blocking receptors. Aldosterone is made in the adrenals, and when in excess, causes fluid buildup and possibly high blood pressure.
Progesterone acts like a diuretic, as a calming agent, reducing anxiety. It calms down nerves and muscles due to its conversion to the sleep-inducing and relaxing metabolites, pregnanolone and allo-pregnanolone. This is helpful for men who are tense or anxious.
Progesterone production diminishes with age, much like the other steroid hormones. Fortunately, it doesn’t decrease as fast as DHEA or pregnenolone.
Symptoms and Signs of insufficient Progesterone are: tense or nervous behavior, anxiety and lack of peace, tense muscles, superficial, nervous sleep, reduced urine flow with increased time to urinate, constipation and swollen abdomen, male pattern baldness and excess body hair, enlargement of breasts (gynecomastia).
Dehydroepiandrosterone (DHEA) is a hormone produced by the body’s adrenal glands. The body uses DHEA to make androgens and estrogens, the male and female sex hormones. DHEA levels peak at about age 25, then go down steadily as you get older. By the time people are 70 to 80 years old, their DHEA levels are only 10% to 20% those in young adults.
In older people, lower than normal levels of DHEA have been associated with osteoporosis, heart disease, memory loss, etc.
Studies show DHEA helps reduce abdominal fat and improve insulin resistance, helps reduce inflammation in the arteries and reduce arterial stiffness. Studies link low DHEA levels with an increase in heart disease.
Several studies suggest that taking DHEA may help improve mood, fatigue, and well-being.
In terms of memory loss, some studies have shown that DHEA improves learning and memory in people who have low DHEA levels.
Most DHEA supplements are produced in laboratories from diosgenin, a plant sterol extracted from Mexican wild yams (Dioscorea villosa ). It is important to choose high quality DHEA supplements. One way to avoid buying a product with contaminated DHEA is to purchase it through a professional health care provider.
If you are considering testosterone and other hormone replacement or are on testosterone and want to take advantage of Dr. Gavin’s expertise in this area, please do not hesitate to make an appointment or visit the website at AzaniMedicalSpa.com