Although the health risks associated with age-related hormonal decline in women, termed menopause, have been thoroughly addressed, it has now been shown that hormonal changes in the aging male are associated with significant health problems. Specialty board certified Dr. To learn more about male hormone replacement, please select one of the following topics. If you are ready to schedule a consultation with Dr.
Turek, please request a consultation here. There is a progressive decline in testosterone production in men with age. Despite the fact that it is not as rapid a drop in hormones as women get with menopause, it certainly is just as real.
This has been termed male menopause, male climacteric, andropause, or more appropriately, partial androgen deficiency in the aging male PADAM.
Serum testosterone levels in men fall progressively from the third decade to the end of life, mainly due to a decline in the cells in the testis that make the hormone Leydig cells. This decline may also be due to changes in hormones GnRH, LH and proteins SHBG, albumin that regulate testosterone production.
What is usually measured in a blood draw is the total testosterone, which is a combination of the free and protein-bound forms. An analogy to explain this is to think of the total testosterone as all of the cars in a parking lot. Importantly, though, only the cars that can start or drive are useful or active.
Free testosterone comprises all of the cars that can start and be driven away, but the protein-bound testosterone are those cars that may or may not start, and those that may or may not be able to be driven away. Thus, the complex physiology of testosterone balance often clouds the interpretation of age-related declining levels of the hormone. In the brain, it influences libido or sex drive, male aggression, mood and thinking.
Testosterone can improve verbal memory and visual-spatial skills. It as also been shown to decrease fatigue and depression in men with low levels. It is responsible for muscle strength and growth, and stimulates stem cells and blood cells in bones and neys.
Penile growth, erections, sperm production, and prostatic growth and function all depend on testosterone. It also causes body hair growth, balding, and drives beard growth.
Thus, testosterone makes us who we are, and influences how we look.
In men with low testosterone levels, testosterone can improve bone mineral density and reduce bone fractures, an effect similar to that found in postmenopausal women on estrogen replacement. Testosterone results in increases in lean body mass, possibly strength and can decrease fat mass. By stimulating erythropoietin, testosterone increases blood counts.
It appears to improve lipid profiles and dilates blood vessels in the heart but no data has yet shown that it reduces heart attacks or strokes.
Testosterone Treatments: Why, When, and How? – American Family Physician
It appears not to alter LDL or total cholesterol levels. Sexual function also improves with testosterone. Most studies agree that sexual drive is improved by testosterone. Penile erections may be improved with testosterone, but only in men with low testosterone levels.
To make an accurate diagnosis of low testosterone, symptoms or findings must accompany a blood draw showing a low testosterone level. This combination makes treatment worthwhile to pursue. Symptoms include decreased sexual desire and erectile dysfunction, changes in mood associated with fatigue, depression and anger, and decreases in memory and spatial orientation ability. On examination, there may be decreased lean body mass with reduced muscle volume and strength, and increases in abdominal girth.
Decreased or thinning of facial and chest hair and skin alterations such as increases in facial wrinkling and pale-appearing skin suggestive of anemia may also be noted. Testicles that have become smaller or softer may also be present. Finally, low bone mineral density with osteopenia or osteoporosis may also suggest a problem. Not all of these findings need to be present at the same time to diagnose the problem.
In fact, many of these symptoms can be attributed simply to the natural and unavoidable consequence of aging. For example, frailty may be due to many causes, some of which include loss of muscle strength, bone fractures, decreased mood, and impaired cognition, symptoms typical of testosterone deficiency.
However, the association of such symptoms along with a low testosterone certainly implicates this as a problem. Because testosterone is found in several forms in the blood, there is debate as to what test is best to diagnose testosterone deficiency.
In general, a total testosterone is ordered first. Presently, measuring testosterone byproducts such as dihydrotestosterone DHTestradiol and dihydroandrosteindione DHEA is not that useful in making the diagnosis. In addition, a DEXA scan is an accurate, quick and painless procedure for measuring bone density or bone loss. Bone density assessments can also be performed periodically during testosterone replacement to assess the bone response to treatment.
Certainly an evaluation for prostate cancer with a PSA and rectal examination is indicated in men who are at risk prior to testosterone treatment.
The ideal testosterone therapy maintains normal concentrations of the hormone without having significant side effects. Types of testosterone therapy in the US. Risk of liver problems. Nonsurgical procedure to place implant. Scrotal patch: daily shaving, variable abpsorption.
Non scrotal patch: skin welts at patch site. Rubs off on partner or ren. Gum or mouth irritation. Prior to starting treatment, a digital rectal examination and serum PSA are important. Within a month or two after treatment is started, symptoms and testosterone levels should be assessed.
During the first year of therapy, patients should be followed regularly to assess clinical response. After the first year, patients who are stable may be followed annually. Annual evaluations should include testosterone, hemoglobin, liver function tests, lipid profile and PSA tests. Bone density and psychological evaluations can be done depending on the original reasons for treatment.
The natural androgen DHT is a metabolite of testosterone. It is a selective androgen because, unlike testosterone, it cannot be converted to estrogens. It is also a potent androgen, binding to receptors more avidly than testosterone. DHT has an effect on several target tissues, including external genitalia, prostate and skin. DHT deficient men have normal muscle mass and are not osteoporotic.
In normal men, DHT supplements suppress pituitary FSH and LH secretion, likely causing infertility. DHEA is available in over-the-counter formulations in the US. It is a steroid hormone made by the adrenal gland and its level progressively declines beginning the third decade of life and beyond. As a consequence of this, studies have attempted to correlate levels of DHEA and DHEA-sulfate with many health conditions.
Clinical trials looking at DHEA for multiple conditions have been inconsistent. However, its value in older men is not well established. There are decreases in growth hormone and insulin-like growth factor-I with age in both men and women. In addition, treatment of GH-deficient adults with growth hormone improves body composition, muscle strength, physical function, and bone density, and reduces blood cholesterol and cardiovascular disease risk. Some of these improvements are in health domains similar to those affected by testosterone.
However, growth hormone treatment is often accompanied by carpal tunnel syndrome, peripheral swelling, joint pain and swelling, breast tenderness, glucose intolerance, and possibly increased cancer risk. In older individuals, growth hormone treatment improves lean body mass and reduces body fat. However, clinically significant functional benefits, prolongation of youth, and life extension have not been demonstrated. This may lead to hypertension, leg swelling, or worsening heart failure.
Weight and blood pressure monitoring are important for at-risk patients on therapy. Testosterone therapy of any type generally leads reduced sperm production. Patients on testosterone should be informed that fertility will be impaired during treatment.
Excessive red blood cell count polycythemia was a commonly observed side effect in a meta-analysis of clinical trials of testosterone therapy. Polycythemia is most commonly seen with injectable testosterone.
Monitoring blood counts is important for patients on testosterone replacement. In addition, testosterone may suppress clotting factors II, V, and VII, and worsen bleeding in patients on anticoagulation. Liver damage has been reported with oral treatments.
However, it is very rarely observed with injectable, transdermal and transbuccal formulations. Although it does not cause sleep apnea, testosterone therapy can worsen existing sleep apnea. Men at risk of sleep apnea include elderly and obese men, and those with chronic obstructive pulmonary disease. Painful breast enlargement gynecomastia due to high levels of estrogen which comes from testosterone can develop during therapy.
Medications call estrogen receptor blockers can treat this side effect. Testosterone therapy is not thought to affect total cholesterol or LDL cholesterol, but the affect on high-density lipoprotein HDL levels remains unclear.
It is reasonable to follow lipid levels during treatment. One of the most concerning risks of androgen replacement is the potential to worsen detected or undetected prostate cancer. However, no link has been made to testosterone replacement and the development of prostate cancer. Careful follow-up of patients at risk for prostate cancer while on testosterone therapy is important. The FDA recommends that testosterone therapy not be given to men with prostate or breast cancer.
A second concern is whether testosterone treatment worsens urinary symptoms in men with enlarged prostates. For this reason, voiding symptoms should be monitored in treated patients. Turek about Male Hormone Replacement. Want to get some cool men’s health news once a week? Comments This field is for validation purposes and should be left unchanged. Tour The Turek Clinic Los Angeles. Tour The Turek Clinic San Francisco.
Male Fertility and Infertility. As this happens, there will be a dramatic increase in age-related health problems too, including cancer, strokes, heart disease and hormone deficiency. Forms of testosterone in the body. SHBG-bound testosterone is hormonally inactive.
The Role of Testosterone in Men. Testosterone effects in the normal Male. Growth, development, maintenance of secondary sex characteristics, sperm production, erections and prostatic function. Improved libido, mood, memory and energy.
Linear growth, closure of the epiophyses, increases bone mineral density. Body and abdominal fat reduction. Stimulates production of serum proteins. Stimulates erythropoietin production which increases blood counts.
Dilates blood vessels in the heart. Suppression of clotting factors II, V, VIIlow HDL-cholesterol. Stimulates stem cell production. Influences body hair growth, especially facial hair. Advantages of Testosterone Replacement Therapy. Low Testosterone Symptoms and Diagnosis. Treatment for Low Testosterone Levels. Blood counts hematocrit and PSA. Rectal exam prostate cancer. Ascertain voiding symptoms, sleep apnea. Consider DEXA scan for bone mineral density.
Assess efficacy: testosterone level and symptoms. Adjust dose for either variable. Assess symptomatic response, voiding symptoms and sleep apnea. Physical exam, rectal exam, testosterone, liver and lipid profile, PSA, and hematocrit depending on formulation. Assess symptomatic response to treatment, voiding symptoms and sleep apnea.
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