Testosterone replacement therapy – man’s best friend or is it

Testosterone – that dynamic hormone turning boys into men and what distinguishes men from women.  When produced adequately, men have all the characteristics associated with manliness – a deep voice, facial and body hair, a strong libido with normal erections, energy, stamina, strength and a sense of well-being and confidence.  But when testosterone levels are low, a man’s world can come crumbling down in a hurry.

What is testosterone and why is it so important?

Testosterone is a sex hormone produced in the testicles and adrenal glands.  It is the equivalent to males of what the hormone estrogen is to women.  Testosterone has far reaching effects for men in helping to regulate sex drive, bone mass, fat distribution, along with muscle mass and strength.  It is also necessary for the production of red blood cells, sperm production, boosts mood along with aiding memory and cognition. 

As a man enters into his 40’s and beyond, testosterone levels may begin to fall as a clinical condition known as hypogonadism makes its appearance.  Hypogonadism (“hypo” meaning low functioning and “gonadism” referring to the testicles) is a condition of low levels of serum testosterone associated with specific signs and symptoms.  A simple blood test can determine a man’s testosterone levels.  A low testosterone level in men is about 300 nanograms per deciliter while the upper normal limit is approximately 1000-1200 ng/dl.  Some conditions that can lead to low testosterone levels are obesity, type 2 diabetes, liver or kidney disease, and hormonal disorders. 

What are the signs and symptoms of low testosterone?

·      Low sex drive or libido

·      Weaker and fewer erections

·      Decrease in muscle mass and strength

·      Thinning bones or osteoporosis

·      Increase in central body fat

·      Difficulty in concentration or memory

·      Feeling depressed or decrease in self-confidence

·      Low energy

·      Problems with sleeping

·      Enlargement of a man’s breast or gynecomastia

If a man has signs and symptoms of low testosterone or hypogonadism and has been tested and shown to have a low testosterone level, this can be an indication for testosterone replacement therapy (TRT).

What is testosterone replacement therapy?

TRT is a class of hormone replacement therapy in which testosterone is being replaced to counter the effects of male hypogonadism. There are several different delivery options for TRT which include injections, patches, gels and implantable pellets, each with their own advantages and disadvantages.  A physician will need to determine which option is the best for each individual man. 

The purpose of TRT is to restore hormone levels in the normal range for men and it should approximate the natural production of testosterone to help alleviate the symptoms of low testosterone without significant side effects or safety concerns. 

Benefits of testosterone replacement therapy

For men who have been experiencing symptoms associated with hypogonadism, using TRT can make a world of difference in improving many of the symptoms of low testosterone.  Here is a look at how TRT may help boost a man’s quality of life:

·      Improved sexual desire and functioning

Men with erectile dysfunction (ED) or who have a low libido with low levels of testosterone, are candidates for TRT.  They will have noticeably improved results in libido enhancement and frequency.  TRT may also benefit bladder function by improving bladder capacity and compliance.

·      Improved bone mineral density

Men who are deficient in testosterone have double the prevalence of osteoporosis than men with normal testosterone levels.  Testosterone helps increase osteoblastic activity in forming bone.  It is advisable to assess bone density at 2-year intervals in men with hypogonadism along with checking serum testosterone measurements in men with osteoporosis.

·      Improved muscle mass and strength

As a man ages, muscle mass decreases while fat mass increases.  This change in body composition leads to reductions in strength and stamina.  TRT appears to be effective in reversing these bodily changes by decreasing fat mass and increasing lean muscle mass.  Studies have shown that there were improvements also in grip strength, and the ability to get up from a chair with ease. 

·      Improved mood, energy and quality of life

A common complaint in men with hypogonadism is fatigue, depression and feeling irritable.  TRT appears to be associated with facilitating improvements in mood, a feeling of well-being, reductions in fatigue and irritability. 

·      Improved cognitive function

There is a strong correlation between higher testosterone levels and improved cognitive performance in regards to spatial abilities, mathematical reasoning, memory and overall cognitive functioning.

·      Improved metabolic syndrome, type 2 diabetes and cardiovascular disease

Metabolic syndrome includes the components of having hypertension, type 2 diabetes, obesity, and cardiovascular disease, all at the same time.  There is strong evidence low testosterone and hypogonadism have a high prevalence in men with metabolic syndrome, type 2 diabetes, and obesity.  TRT in men with metabolic syndrome appears to have a beneficial effect on improving a man’s quality of life but more long-term interventional studies are needed to assess the effect of TRT on mortality in men with low testosterone.

Risks of testosterone therapy

Even though TRT may seem to be the fountain of youth for men, there are clear risks associated with it.  These risks depend upon the man’s age, life circumstances and medical conditions.   Understanding TRT may not be suitable for every man and should only be administered under the supervision of a medical doctor, can help avoid unnecessary problems that could arise.

·      Prostate cancer

The thing to keep in mind with prostate cancer is there is no compelling evidence that testosterone has a role in causing prostate cancer.  It should be noted that prostate cancer does more become more likely at about the same time when testosterone levels are beginning to decline in men.  The main concern with TRT is when a man already has been diagnosed with prostate cancer.  There is strong evidence that testosterone can stimulate growth and aggravate symptoms in men with locally advanced and metastatic prostate cancer.  Once a man has been successfully treated for prostate cancer and there is no evidence of residual cancer, can he then be treated for TRT if he has hypogonadism.

·      Suppression of fertility

      One consideration men need to account for if using TRT is the possibility of suppressing    

      fertility.  Testosterone produced naturally is important for male fertility but two other

      hormones, luteinizing hormone (LH) and follicular stimulating hormone (FSH) play

      important roles too.  The hypothalamus in the brain produces a chemical called

       gonadotropin-releasing hormone (GnRH) that sends a message to the pituitary gland to

       produce LH and FSH.  But because TRT increases testosterone levels, the hypothalamus

       reduces the production of GnRH which in turn causes the pituitary gland to no longer

       produce LH and FSH so sperm production declines.  A lower sperm count means it will

       make it more difficult for a man to impregnate his partner.

·      Increases severity of sleep apnea

     If a man is dealing with sleep apnea, TRT may make it much worse.  A man who is using

TRT and develops sleep apnea should inform his doctor and have a sleep studydone with the treatment of continuous positive airway pressure (CPAP) if necessary.  If a man is unable to tolerate CPAP then the testosterone should be reduced or discontinued.

·      Polycythemia

Polycythemia is a condition that TRT may stimulate.  It is a condition where the body makes too many red blood cells which increases the risk of blood clots.  Blood clots in the veins, also known as venous thromboembolism (VTE) include deep vein thrombosis (DVT) and pulmonary embolism (PE).  Periodic blood draws are indicated when on TRT to assess hematocrit levels that can indicate polycythemia.

·      Possible problems associated with administration of  TRT

The administration of TRT can have some possible downsides. 

One form of delivery of TRT is injecting testosterone.  Injections of testosterone are given once every 2 weeks.  The drawback of this is the injection delivers a large dose of testosterone in the beginning but it drops off fairly quickly by the end of the two weeks before the next injection is to be given, leaving a man feeling the effects of his testosterone levels waning.  There is also the possibility of scarring from the frequency of injections.

Patches are another delivery form for TRT providing a more steady dose but they can cause skin irritation where they are applied to on the body. 

Gels used in TRT can have a side effect of causing dry, flaking skin on the area of the body the gel is rubbed onto.  A man needs to remember to thoroughly wash his hands after applying the gel to not expose women or children to any testosterone residue on the skin that may alter their hormonal balance. 

To use testosterone replacement therapy or not

TRT needs to be carefully considered by all men and their physicians to determine if it is the appropriate treatment method after all other medical conditions have been ruled out.  Men should realize TRT is not a substitute for taking care of oneself.  If a man comes in who is obese, has a poor diet and doesn’t exercise, TRT will not magically cure them of their ills. 

The goal of TRT should be to help a man with hypogonadism achieve the highest quality of life, reduce disability, and to add life to his years.  When that happens, then TRT has done its job.