“Light Reading for Sick Rooms and Parties”
It may be worthwhile for the reader to review the recent two blogs on this subject. It may seem a bother, if not a tough slog, to familiarize yourself with the details of hormone replacement. Yet an uninformed recipient is an ill-advised patient. What you don’t understand in these blogs needs to be understood before you begin replacement. Copy this information, supplement it from reliable web sites (e.g. Mayo Clinic, CDC.gov) and review in detail with your physician.
In today’s third and final blog on testosterone replacement we will focus on 4 area: accurate testing, full disclosure, proper monitoring, and replacement options.
Initial screening should include a test for Total Testosterone and Free Testosterone on a blood sample drawn in the morning. Testosterone levels are highest in the morning. Later, if replacement is deemed appropriate and started and the replacement is by injection, subsequent testing should be done 48 hours after injection as this will reflect peak levels. If replacement is done
by gel or patch, subsequent testing can be done at any time.
If Total or Free Testosterone is reported to be below the lowest normal (e.g. less than 200 when 200-1000units reflects the laboratory normal values) then a Leutinizing Hormone, Dihydrotestosterone, and a current PSA and Complete Blood Count should be obtained. Leutinizing Hormone is measured to determine if the low testosterone is due to a deficiency of the pituitary glad in its role to stimulate testosterone production in the testes. If Leutinizing Hormone is also low it does not mean that replacement is not indicated, but it does suggest that the pituitary gland should be studied further to determine if other hormones it regulates are not up to par.
Dihyrotestosterone levels are not required by every physician. I draw this because it has been found that blocking it can help men with enlarged prostate
symtoms, and male pattern hair loss, without compromising the muscle mass preservation that accompanies testosterone replacement.
Prostatic Specific Antigen is followed because testosterone stimulates prostate growth; any sudden rise of the PSA should be investigated further.
The Complete Blood Count, or more specifically the Red Blood Cell Count (hemoglobin and hematocrit) are measured and followed because testosterone
replacement increases red blood cell production. If the red cell count exceed normal range it will become a danger because it makes the blood “too thick”
and risks abnormal clotting.
Before starting the candidate should know what are the risks of testosterone replacement. The prostate will grow, and more rapidly resulting in potential
symptoms (decreased stream force, frequency (especially getting up in the middle of the night). The red blood count will likely increase and dosages may
need to be reduced or replacement eliminated altogether if the red cell count gets too high.
Because prostate cancer growth is stimulated by testosterone the greatest concern is that replacement would increase the risk of developing prostate cancer. This has been studied extensively for decades and no data supports an increased risk for cancer if replacement stays within the normal ranges. However
it does not decrease the risk for prostate cancer either which is why early diagnosis is important; testosterone replacement would be stopped with the diagnosis of prostate cancer. After treatment however, testosterone is sometimes restarted.
Testing is done frequently the first year, both to determine response, monitor PSA and blood count, and assure that too much is not being prescribed.
Testing is a significant expense and many insurance companies balk at covering this service as well as replacement hormone. This is especially true when
baseline tests indicate clearly a low level (e.g. 220) but not quite below the considered lowest normal value. Frequently men will decide that they still
want the replacement to see what effect it will have on them, and then decide whether to “fight the insurance” or simply pay for it out of their own pocket.
After the first year and when proper dosing is determined, testing is done at 6 month intervals.
All of my patients are given the option of testosterone injections. It is simple and incredibly less expensive than topical replacement. It also is arguably closer
to how the body works because topical testosterone is largely converted by enzymes in the skin to Dihydrotestosterone and circulates exclusively in that form until eventually metabolized. Testosterone injections however have at least one pass through the body as testosterone before being converted to dihydrotestosterone by the liver.
Aside from being 20 to 50 times more expensive than testosterone injections, the skin applied testosterone create important obligations. It is important that
it be applied in such a way that it does not come in contact with anyone else.
Testosterone injections are easy to administer and are done once a week. More frequently than that is not necessary, and less frequently can cause peaks and valleys of hormone levels noticed by the man.
However, some men are just not keen on giving themselves injections and the skin applied testosterone is the right thing for them.
Important: There are no oral preparations of testosterone that are not either useless (except in separating you from your money) or severely toxic.
Therefore there are no FDA approved oral testosterone products. Also there are no oral “precursor, stimulators, enhancers of testosterone”. DHEA (Dihydroepiandrosterone) is sometimes called “the mother of all (sex) hormones” because it is metabolized eventually to both testosterone and estrogen.
Athletes (Mark McGuire admitted as much) will take oral DHEA (legitimately available over the counter) in hopes that it will boost testosterone.
It may, but only for a short time, and then in men it often boosts estrogen as least as much or more. It is however used in women (low dose) to help
with their libido, because in the case of women the metabolism goes toward testosterone production. If it has a testosterone effect in women it is often accompanied by masculinizing changes (unwanted hair, voice…) that are not endearing to the woman.
The reader might get the impression from these discussions that testosterone replacement is dangerous. It can be, if not done properly. But that can be said about thyroid replacement, insulin replacement and any medical treatment.
I have helped hundreds of men in the assessment of their testosterone levels, suitability for replacement, and have dozens of male patients on testosterone replacement who appreciate excellent results in the context of all the requirements to do so safely.
Though I have devoted three blogs to this topic, they are not inclusive of many more important details that would need to be considered in the unique context of each individual. They are a good start however, in your discussions with your physician. Direct to consumer marketing by pharmaceutical companies is willfully misleading at worse, and grossly inadequate disclosure at best. These blogs are offered to help you with your due diligence before embarking on any voluntary drug treatment, including testosterone replacement.
“Just a G.P.”
by B. Kiessling, M.D.
Medical Director, Primary Care Associates