Indian J Urol. 2014 Jan-Mar; 30(1): 27.

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, Starr 900, New York, NY, USA

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Testosterone replacement therapy (TRT) is a widely used treatment for men with symptomatic hypogonadism. The benefits seen with TRT, such as increased libido and energy level, beneficial effects on bone density, strength and muscle as well as cardioprotective effects, have been well-documented. TRT is contraindicated in men with untreated prostate and breast cancer. Men on TRT should be monitored for side-effects such as polycythemia, peripheral edema, cardiac and hepatic dysfunction.

Keywords: Hypogonadism, side-effects, testosterone replacement therapy

Testosterone has many beneficial effects, including increasing bone strength and density, inducing hematopoiesis, driving sexual function and libido, providing a cardioprotective effect and increasing muscle strength.[1] Testosterone levels are known to decline as men age. The Baltimore Longitudinal Study of Aging reported the incidence of hypogonadism as 20% in men over 60 years of age, 30% in men over 70 years and 50% in men over 80 years of age.[2]

As men age, a decline in testicular production of testosterone are seen, as well as an increase in sex hormone binding globulin, both of which act to decrease bioavailable testosterone.[3] With this gradual decline, the beneficial effects of testosterone could be diminished and negatively affect physical and emotional well-being. Testosterone replacement therapy (TRT) is a reasonable treatment option often discussed for men with low testosterone levels and symptoms of hypogonadism. When replaced, many of the positive effects of testosterone are regained.[4] These positive results have led to a drastic increase in the use of testosterone replacement for men with symptomatic hypogonadism, though long-term data is lacking on the safety.

While the beneficial effects of testosterone are rarely disputed and widely publicized, there is a paucity of the literature on the risks of testosterone use. Any man who has a comorbidity that precludes TRT should be informed of all risks. Factors such as exacerbation of prostate cancer, male breast cancer, worsening benign prostatic hyperplasia (BPH), polycythemia and an increased risk of obstructive sleep apnea (OSA) should be considered when administering TRT to a patient. The goal of this review is to highlight the risks and summarize the current literature on safety of TRT.

One of the major risk factors associated with the administration of testosterone supplementation is its effect on the prostate. We know the prostate to be an androgen-dependent gland and conversely, anti-androgen agents can decrease prostate volume in patients with BPH. As the population continues to age, both the incidence of BPH and late-onset male hypogonadism will continue to rise and practitioners will need to be comfortable with counseling men on the effect of TRT on the prostate.[5]

In a landmark randomized, double-blind, placebo-controlled trial of 44 hypogonadal men, Marks et al. showed that TRT for 6 months improves serum androgen levels, but had little effect on prostate tissue androgen levels, tissue biomarkers and/or gene expression.[6] Testosterone supplementation has been shown to increase prostate size by 12%,[7] but lower urinary tract symptoms (LUTS) and urinary retention do not worsen in men on testosterone therapy.[8,9] Similarly, the presence of hypogonadism in 312 men with reportable LUTS was not predictive of worsening International Prostate Symptom Scores (IPSS) or maximal urinary flow rates.[10]

In fact, some series report an improvement in LUTS after 1 year of TRT.[11,12] In the most recent, randomized controlled trial, 52 men were randomly assigned to receive TRT. At 1 year, the 23 men randomized to 250 mg of testosterone enanthate every 4 weeks reported significant improvements in IPSS and maximal urinary flow rates compared with baseline and controls.[12] At no point in this trial did any patient require additional medication or suffer urinary retention.

While older men on testosterone therapy do have an increase in overall prostate size, this increase in size does not differ from the increase in prostatic hypertrophy seen in elderly men not on testosterone therapy.[13] Taken together, TRT does not appear to grossly worsen LUTS and is not contraindicated in men diagnosed with BPH.

It has been over 60 years since Hodges and Huggins described a relationship between serum testosterone levels and prostate cancer progression.[14] Later in 1982, Fowler and Whitmore reported that exogenous testosterone given to patients with metastatic prostate cancer had worse outcomes.[15] Today androgen deprivation therapy remains a cornerstone of treatment for men with advanced prostate cancer, so it is no surprise that TRT is contraindicated in men with diagnosed prostate cancer, as well as high-risk patients, which includes men with first-degree relatives with prostate cancer and African-Americans who have a prostate-specific antigen (PSA) >3 ng/mL.[4,16]

Recently, there has been a paradigm shift whereby TRT usage has increased despite this potential risk. Many longitudinal studies investigating the relationship of endogenous testosterone levels and subsequent risk of prostate cancer failed to find any association.[17] As such, prostate cancer incidence in men on testosterone therapy is similar to men not on testosterone therapy.[18,19] Similarly, in a 3-year prospective trial, the incidence of prostate cancer was similar among men receiving TRT and controls.[20] In a large meta-analysis of 18 prospective studies that included over 3500 men, there was no association between serum androgen levels and the risk of prostate cancer development.[21] Morgentaler et al. proposed a saturation theory where prostate growth becomes insensitive to changes at normal androgen levels due to saturation of the androgen-receptor; however, there is exponential growth at castrate levels.[22] This theory may explain why testosterone does not directly cause prostate cancer,[23] but it has been shown to accelerate the development of prostate cancer.[24,25]

For premalignancy, prostatic intraepithelial neoplasia (PIN) appears to be a risk factor for developing prostate cancer, however this association has been mostly demonstrated for high-grade disease.[26,27] There is a lack of long-term data on the use of TRT in men with PIN. In one study, 12 months after TRT, only one patient out of 20 men with previous PIN developed overt prostate cancer.[28]

For men who have previously undergone definitive treatment for prostate cancer, the usage of TRT is becoming more accepted. TRT does not appear to increase cancer recurrence in hypogonadal men following radical prostatectomy.[29] In the most recent study by Pastuszak et al., the authors retrospectively reviewed a cohort of 103 men who underwent prior radical prostatectomy and were treated with TRT. Despite a significant increase in PSA in men receiving TRT, there were twice as many cancer recurrences in the control group after 36 months of follow-up.[30]

For men with untreated prostate cancer on active surveillance, TRT remains controversial. However, several studies have shown that TRT is not associated with progression of prostate cancer as evidenced by either PSA progression or gleason grade upstaging on repeat biopsy.[31,32] In the most recent study by Morgentaler et al., 13 men with symptomatic hypogonadism and untreated prostate cancer received TRT for a median of 2.5 years and no local prostate cancer progression or distant disease was observed.[33]

While there have been reports of metastatic prostate cancer in older men who are on testosterone therapy,[20] these are mostly anecdotal. Because of this potential risk, practitioners are often reluctant to administer testosterone in patients they believe may be at high risk for prostate cancer or whom they suspect may have the low-grade disease. Men on TRT should have frequent PSA monitoring; any major change in PSA (>1 ng/mL) within the first 3-6 months may reflect the presence of a pre-existing cancer and warrants cessation of therapy.[34] Current guidelines on the frequency of PSA monitoring and role of pre-treatment transrectal ultrasound guided prostate biopsy are lacking.[35] Taken together, there has been consistent rejection that TRT causes development of prostate cancer in men, however administration of TRT for hypogonadal men previously treated for high-risk prostate cancer should be taken with caution.

While there is no known physiologic link of testosterone directly to the development of breast cancer, it has been suggested that high levels of testosterone may lead to increased aromatization to an active derivative of estrogen, which ultimately may stimulate breast tissue receptors and increase the risk of male breast cancer.[36]

The role of testosterone in breast cancer development is yet to be fully understood.[37] Currently, several case reports exist[38] and one retrospective review sites an incidence 11% in 45 men on long term TRT over 10 years.[39] Future prospective studies with longer follow-up will determine if such association between TRT and male breast cancer truly exists.

Testosterone leads to an increase in hemoglobin by as much as 5-7%[1,25] through its effect on the production of erythropoietin, which can dramatically improve symptoms of anemia in men.[40,41]

Studies looking at the occurrence of polycythemia as a negative side-effect in men on testosterone therapy are rare. Despite this, polycythemia is an accepted side-effect of TRT. While testosterone exerts a positive effect in men with baseline anemia, it can lead to polycythemia in over 20% of men treated on TRT.[42] Polycythemia may lead to an increased incidence of vascular events, including stroke, myocardial infarction and deep vein thrombosis with possible pulmonary embolus.[42] While these complications are all possible with polycythemia, their theoretical occurrence has not been demonstrated to occur in men on TRT.[43]

Because of this risk of polycythemia, men undergoing TRT should not only have their complete blood count (CBC) monitored during their therapy, but should also have a baseline CBC drawn before testosterone therapy is initiated. While on testosterone therapy, if the hematocrit (HCT) rises greater than 54%, testosterone therapy should be held until the HCT normalizes. If it is restarted after normalization, it should be performed so at a lower dose with continued careful monitoring.[16]

OSA is a risk associated with TRT in men, but its etiology is not particularly well understood. While some studies suggested that there is no association between OSA and TRT,[44] others have demonstrated that that OSA occurs in men undergoing TRT and when supplementation is stopped, the OSA resolves.[45]

While no clear link has been established, men on TRT should be counseled on the risk of potential OSA when therapy is started. They should be monitored for increased symptoms, such as snoring while sleeping or fatigue. If patients starting TRT already carry a diagnosis of OSA, physicians should counsel these patients that TRT may worsen their symptoms. While, OSA remains to be a relative contraindication to initiation of TRT, more research needs to be completed on this association in order to gain a better understanding of its etiology if there is one at all.

The systemic effects of TRT may be exacerbated in men with limited cardiovascular reserve. Previous dogma held that androgens could have atherogenic potential. In a randomized, placebo-controlled trial, Basaria et al. reported an increased risk of cardiovascular events in men randomized to TRT; however, this small cohort had a high prevalence of chronic disease.[46] Today, current literature suggests that TRT has a neutral to beneficial effect on reported cardiovascular events.[47,48] Because some men may have a limited cardiovascular capacity, clinicians prescribing TRT must be cautious with respect to its ability to cause edema.[49] Until date, no longitudinal studies examine the impact of TRT on the cardiovascular system, however some studies suggest that TRT may serve as an adjunct rehabilitative therapy in patients with congestive heart failure (CHF).[50,51,52]

While topical testosterone delivery systems avoid first-pass hepatic metabolism, there remains concern regarding TRT in patients with chronic liver disease. The majority of reports of liver toxicity and jaundice are limited to orally-administered alkylated forms of testosterone.[53] However, a small prospective study representing a cohort of cirrhotic patients demonstrated topical gels to be safe and efficacious.[54] It has also been shown that TRT may improve hepatic function in patients with end-stage liver disease.[55] Because of these mixed results, clinicians should be aware of the possible risks associated with TRT in men with hepatic dysfunction and counsel these men accordingly.

Because TRT is known to cause water retention, caution with testosterone use in patients with chronic renal insufficiency is often advised. In patients with end-stage renal disease (ESRD) on dialysis, fluid shifts are less of a concern in patients on TRT since the fluid retention can be handled with dialysis. While polycythemia may be an adverse side-effect, this is a potential benefit in patients with chronic renal failure and anemia.[56] Furthermore, the half-life of testosterone elimination after withdrawal appears similar between patients with and without ESRD.[56] Few studies have assessed the effects of TRT in patients with chronic kidney disease; however, small studies have suggested that TRT has anabolic effects among ESRD patients, even in the absence of hypogonadism. Aside from frequent monitoring of congestive symptoms and peripheral edema in this select population, TRT appears to be safe for patients with chronic kidney disease without dose adjustment.[57]

When testosterone reaches supra-therapeutic levels, aggressive behavior and increased rates of suicide among adolescent users have been reported;[58] however, no study has documented a negative impact on cognition in men patients receiving TRT. In fact, studies have shown that testosterone replacement to eugonadal levels may improve or stabilize cognitive function.[59,60,61] Lower levels of testosterone have a negative impact on spatial and verbal abilities, as well as cognitive function; therefore, it is no surprise that normalizing testosterone levels results in cognitive improvements.[62,63]

With exogenous testosterone supplementation, the pulsatile release of gonadotropin-releasing hormone is blunted and the release of follicle-stimulating hormone and luteinizing hormone are depressed. As such, a decrease in spermatogenesis is seen.[64] While this effect may not be of importance to many men who have completed their families, physicians prescribing TRT need to be aware.

When serum levels of testosterone are increased, a concurrent increase in the secretion of sebum occurs, which can lead to acne. Despite this known association, this effect is typically minimal.[65] Case reports regarding testosterone supplementation leading to changes in hair patterns have been documented; however no randomized, placebo-controlled trials exist. Various topical and intramuscular injectable forms of testosterone are associated with a variety of skin reactions, mainly erythema and pruritus in up to 60% of users.[20]

TRT is associated with external, physical changes in the men. Exogenous testosterone is known to cause an imbalance in the hypothalamic-pituitary axis. As such, testosterone can be converted to estrogen by aromatization. Excess estrogens may lead to gynecomastia and/or breast pain, both of which may be seen in 10-25% of men on TRT.[66] The ratio of estradiol to androgens is the key factor in the development of gynecomastia rather than absolute increases in androgens themselves.[66] Clinicians must be aware of non-iatrogenic causes of gynecomastia and therefore the appropriate work-up should be sought out to rule out other pathology, especially if there is any breast tenderness or unilateral gynecomastia. Only a few case-reports describe a relationship between male breast cancer and TRT.[38,39]

In addition, excess estrogens may cause an increase in visceral obesity. With vigilant monitoring of serum estrogen levels, TRT has been shown to promote weight loss.[67] Well-known to many prescribers of TRT is a risk of water retention and/or edema. The etiology of this association remains unclear to date.[68] The degree of retention is generally mild. As mentioned above, men on TRT with a history of CHF should follow closely[69].

TRT has numerous benefits that can great enhance a patient's quality-of-life. Before prescribing TRT, one must be conscientious of its adverse effects. Data on the safety of TRT specific to our aging population is not currently available; however TRT has been linked to prostate cancer, BPH, polycythemia and OSA. A full assessment of the morbidity of TRT would require a large-scale, randomized, controlled trial. To date, physicians remain in a quandary about the best approach to care for men with symptoms of hypogonadism. TRT, when given to appropriately selected patients with vigilant monitoring as outlined in this review and in , can bring improvements in quality-of-life, energy level, libido, muscle mass, cognition and bone density.

Potential risks of TRT and associated monitoring strategies

Source of Support: Nil

Conflict of Interest: None declared.

Articles from Indian Journal of Urology : IJU : Journal of the Urological Society of India are provided here courtesy of Medknow Publications

Originally posted here:
Risks of testosterone replacement therapy in men

Overview

The good news is that therapy is often very effective. The goals are to restore sexual functioning, increase libido and sense of well-being, prevent osteoporosis by optimizing bone density, restore muscle strength and improve mental functions. Our aim is to bring your levels of serum testosterone back to high normal levels. Beyond this, we aim to normalize other hormones that may be abnormal as well. These include, thyroid hormone, DHEA, estradiol (the main female hormone), and prolactin.

There are a number of ways to treat this condition including transdermal (through the skin) patches and gels, injections, and long-acting slow release pellets. Each modality has its own advantages and disadvantages. Factors include: ability to get good levels, transmissibility to others, frequency and ease of use, and personal preference.

It is important to note that testosterone is not available orally. This is because all drugs absorbed in the stomach go to the liver first. The liver thus gets a very high concentration of the medication. In the case of testosterone, this can increase the chance of liver disease and cancer. This is not the case when it is given by other modalities.

Topical Therapy/Applied to Skin or Mucous Membranes

Testosterone can be applied to the skin or to mucous membranes (the inside of the nose or mouth.) Mixed with the testosterone are specific ingredients that help get it into the bloodstream, and then to the rest of your body. Most often, this is the first line therapy. The range of options and number of branded and generic preparations continues to grow.

Locations

The testosterone may be applied to the:

Advantages/Disadvantages

>Daily Use

Most men start with the topical medications, as they are less intimidating. If for some reason, a man doesnt like it, he just doesnt have to do it the next day.

However, to be effective, all of the topicals must be placed every day. For some men, this is a non-issue. For others this is a burden. They may not be able to remember to put it on consistently. They may not like the way it feels, smells, or tastes.

>Variable Absorption

Many men get good absorption and are able to attain good blood testosterone levels. However, a significant number of men are not able to absorb the medication, and never get good levels.

We always check levels, and switch to a different modality of testosterone replacement, if blood levels are not good enough. In general, we find that if a man is not getting good absorption with one gel or solution, he will not get good levels with a different one. Typically, we will switch to a totally different method.

>Activity Limitations

Since the medications take some time to be absorbed, it is important not to remove them until they have had adequate time to be absorbed.

For the gels and solutions, this is a minimum of two hours. Thus, the user should not shower, swim, or work-out until at least two hours after they have been applied.

For the intranasal (up the nose) gel, which is used three times daily, it is important not to sniff or blow your nose for an hour after use.

>Transmissibility

Though the gels and solutions take a minimum of two hours to be absorbed, they are not completely absorbed at this time. Thus, it is important to shower prior to having skin to skin contact (particularly with women and/or children) to the area where the medication was applied. To avoid transmissibility, you can simply put on a T-shirt.

We usually have our patients apply their once daily medications at night, then sleep with a T-shirt, and shower in the morning, so they are finished with the application for the day.

Most men with pregnant wives or children are not particularly comfortable with using the gels or solutions. There should be no transmissibility issue with the patch or the nasal gel.

>Local Irritation

Since the medication is placed on a particular surface (skin or mucosa) it may cause local irritation.

Local irritation seems to be most common with the patch, where our experience shows that almost no men can tolerate it. Men who are very motivated to use the patch can put a thin layer of hydrocortisone cream over the area first. This often cuts down on the irritation, without decreasing absorption.

For the topical gels and solutions, many men develop rashes or burning. This may be true, even if they rotate the site of application. However, many men have no skin issues whatsoever.

Injections

Testosterone may be injected into the layer of fat underneath the skin (subcutaneously) or into the muscle (intramuscularly- IM), usually the thigh, arm, or buttock. This method has been used by physicians for years, and predates the use of topical testosterone by decades. ( It is also the method that has been most abused by bodybuilders and athletes.)

Traditionally, testosterone was injected only intramuscularly. However, experts have recognized that it is also equally well absorbed when injected into the fat underneath the skin. The needle is much shorter this way, and most men report preferring this technique.

Method

There are various formulations of injectable testosterone. The most common are testosterone cypionate and testosterone enanthate. Testosterone cypionate is the one that virtually all physicians, including us, prescribe.

The dosage is dependent on the individual. In general, we are aiming for men to feel better, which usually correlates to being in the high normal range. We have men injecting as low as 100 mg weekly, and as high as 220 mg weekly. We follow both symptoms and blood work.

Some men notice the ups and downs correlated to the variable levels during the week. These men are then counseled to split the dosage into two, and give themselves two injections per week. This often avoids the peaks and valleys experienced if the medication is given only once during the week.

Many physicians require their patients to come into the office weekly for their injections. This is, of course, burden for many patients. In fact, most patients cannot follow through and drop out of treatment. Other physicians, using the same rationale, give their patients a large dosage on a biweekly or monthly basis. However, this makes the patients have huge peaks and valleys based onhow much is in their system. It also results in more side effects.

The rationale for requiring the patient to come into the office is that this is a restricted drug, and could be abused by the patient. This makes no sense to us for several reasons. The prescribing practitioner knows how much s/he is prescribing. If the patient is running through it much faster than he should be, then there is a problem which is immediately apparent. Also, if a patient wants to abuse steroids, he can just obtain them illegally at many gyms, and doesnt need the physician in the first place. By putting a reasonable and doable treatment plan in place, we feel it is more likely that patients will follow a safe medical regimen.

How is Injectable Testosterone Supplied and How Much Does It Cost?

Testosterone cypionate comes in 10cc and 1cc vials. We strongly recommend our patients get the 10cc vials, as the liquid is very thick (viscous) and it is quite hard to empty the 1cc vials. It is usually more expensive, per cc, to purchase 10 vials of 1cc than it is to purchase 1 vial of 10ccs.

It is available at almost all pharmacies, but sometimes needs to be ordered in advance.

Many drug plans will only pay for one month of medication at a time, which means they will not release a 10cc vial. Fortunately, the medication is relatively inexpensive, and sometimes it is even cheaper to purchase the 10cc vial without using your prescription plan than it is to pay a monthly co-pay and get the 1cc vials. Using a website like goodrx.com or rebates.com, you can make the pharmacies compete for a reasonable price, and a 10cc vial should cost between $35 and $55 (without using your prescription plan).

Thus, for patients without insurance, or with poor drug coverage, the injectable testosterone is by far the cheapest option.

Advantages of injectable testosterone

Disadvantages of injectable testosterone

>Not Bio-identical

Testosterone cypionate is the oil-soluble 17 (beta)- cyclopentylpropionate ester of the androgenic hormone testosterone. In other words, it is not bio-identical testosterone. Men have been making their own testosterone since before we evolved into homo sapiens. But, we have not been making testosterone cypionate. Thus ,there may be some long term side effects of testosterone cypionate that we are not aware of. (Testosterone pellets are an excellent alternative that are bio-identical.)

>Side-Effects

There do seem to be more side effects from testosterone cypionate than from bio-identical testosterone. These include more acne and more increases in hematocrit and estrogen. It is unclear whether this is because there are more peaks and valleys in weekly or biweekly doses than with daily application treatments.

>Self-Injections can be Uncomfortable

Testosterone cypionate is a very thick (viscous) liquid. It is slightly difficult to draw up, and somewhat uncomfortable to inject.

>Compliance

Men do have to remember to give themselves an injection every week, or twice weekly. For some men this is simply not feasible, either because they dread it, or they simply cant remember.

Testosterone Pellets

Testosterone pellets can be inserted in the fat underneath the skin (subcutaneously) once every three months. This is done in the office, and takes less than ten minutes. It has become the most popular method in our practice.

The pellets each contain 75 mg of testosterone. Each pellet is approximately the size of a grain of rice.

In terms of dosing, we can always get good levels of testosterone which we can adjust simply by varying the number of pellets placed, all of which go through the same small skin incision.

How is it Done?

Most of the time, the pellets are placed through a small incision in the skin of the buttock. The incision is so small it is closed with a butterfly bandage (steri-strip). The location is chosen so that it is below the belt line, and above where you sit. No matter how many pellets are placed, only one small skin incision is made.

After the procedure, a butterfly dressing is put on the small nick to hold the edges together, and then a clean dressing. The dressing is waterproof so a man can take a shower with it on. The dressing can be removed after 48 hours. The butterfly dressings then fall off on their own.

We ask our patientsto compress the site and apply ice for a total of 15 minutes, directly after the procedure to limit swelling and bleeding.

Advantages

>Compliance

Men love the fact that they only need to think about this once every three months. Once we have determined the correct dosage, they only need to come to the office once every three months.

>Levels

Unlike the topicals, we can always get men good levels with the pellets.

>Bio-identical

The testosterone pellets are bio-identical. This means that they are exactly what your body makes. Thus, any side effects would only be due to the dosing not to the actual medication itself. In our practice we have a strong preference for bio-identical hormones for this exact reason.

>Cost

Most insurance companies pay for this medication and for the procedure. (However, if they do not, it is much more costly than the testosterone injections.)

Disadvantages

>Discomfort

Some men do not like the procedure. Either they are intimidated by the procedure itself, or they have some post-procedure swelling, bruising, and/or discomfort.

>Infection

Slightly less than 1% of the time, the site can have a small infection. Almost invariably the mans body responds by opening up the tract that the pellets went through and spitting them out. We have never had an abscess or needed to drain the area. We have not needed to give systemic antibiotics.

See the rest here:
Testosterone Replacement Therapy Werner, MD

A hormone in both men and women

Testosterone is a hormone found in humans, as well as in other animals. The testicles primarily make testosterone in men. Womens ovaries also make testosterone, though in much smaller amounts. Testosterone production starts to increase significantly during puberty, and begins to dip after age 30 or so.

Testosterone is most often associated with sex drive, and plays a vital role in sperm production. But it also affects bone and muscle mass, the way men store fat in the body, and even red blood cell production. A mans testosterone levels can also affect his mood.

Low levels of testosterone can produce a variety of symptoms in men, including:

While testosterone production naturally tapers off as a man ages, other factors can cause hormone levels to drop. Injury to the testicles and cancer treatments such as chemotherapy or radiation can adversely affect testosterone production. Chronic diseases and stress can also reduce testosterone production. Some of these diseases include:

A simple blood test can determine testosterone levels. There is a wide range of normal or healthy level of testosterone circulating in the bloodstream. The normal range of testosterone for men is between 250 and 1100 ng/dL for adult males, and between 8 and 60 ng/dL for adult females, according to the Mayo Clinic. Ask your doctor to test your testosterone levels if you have concerns about low testosterone (low T).

Unusually low testosterone levels could be a sign of pituitary gland problems. The pituitary gland sends a signaling hormone to the testicles to produce more testosterone. A low T test result could indicate that the pituitary gland isnt working properly. A young teen with low testosterone levels may simply be experiencing delayed puberty.

Moderately elevated testosterone levels in men tend to produce few noticeable symptoms. Boys with higher levels of testosterone may begin puberty earlier. Women with excessive testosterone may develop masculine features.

Abnormally high levels of testosterone could be the result of an adrenal gland disorder, or even cancer of the testes. High levels may also occur in less serious conditions. Congenital adrenal hyperplasia, which can affect males and females, is a rare but natural cause for elevated testosterone production. Your doctor may order other tests if your levels are exceedingly high.

Reduced testosterone production, a condition known as hypogonadism. This doesnt always require treatment. A low T test result should trigger a check of your prostate health and red blood cell production. Serious medical issues sometimes coincide with decreased testosterone production, and should be diagnosed and treated if necessary.

You may be a candidate for testosterone replacement therapy if low T is interfering with your health and quality of life. Artificial testosterone can be administered orally, through injections, or with gels or patches on the skin.

Replacement therapy may produce desired results, such as greater muscle mass and a stronger sex drive. However, the treatment does carry some side effects. Oily skin and fluid retention are common. The testicles may also shrink, and sperm production could decrease significantly. Some studies have found no greater risk of prostate cancer with testosterone replacement therapy, but it continues to be a topic of ongoing research.

Research shows little evidence of abnormal or unhealthy psychological changes in men receiving supervised testosterone therapy to treat their low T, according to a study in the journal Therapeutics and Clinical Risk Management.However, mental and physical risks are involved in self-administration of artificial testosterone. Anyone abusing synthetic testosterone, also known as anabolic steroids, may experience episodes of aggressive or violent behavior, along with physical side effects. Bodybuilders, athletes, or anyone who seeks to build muscle mass or achieve other benefits from artificial testosterone should be aware of these risks.

Testosterone is most commonly associated with sex drive in men. It also affects mental health, bone and muscle mass, fat storage, and red blood cell production. Abnormally low or high levels can affect a mans mental and physical health. Your doctor can check your testosterone levels with a simple blood test. Testosterone therapy is available to treat men with low levels of testosterone. If you have low T, ask your doctor if this type of therapy might benefit you.

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Testosterone: What It Is and How It Affects Your Health

How Is Low Testosterone Treated?

Testosterone deficiency can be treated by:

Each of these options provides adequate levels of hormone replacement; however, they all have different advantages and disadvantages. Talk to your doctor to see which approach is right for you.

Men who have prostate cancer or breast cancer should not take testosterone replacement therapy. Nor should men who have severe urinary tract problems, untreated severe sleep apnea or uncontrolled heart failure. All men considering testosterone replacement therapy should undergo a thorough prostate cancer screening -- a rectal exam and PSA test -- prior to starting this therapy.

In general, testosterone replacement therapy is safe. It is associated with some side effects, including:

Laboratory abnormalities that can occur with hormone replacement include:

If you are taking hormone replacement therapy, regular follow-up appointments with your doctor are important.

Like any other medication, directions for administering testosterone should be followed exactly as your doctor orders. If you are unsure or have any questions about testosterone replacement therapy, ask your doctor.

More:
Testosterone Deficiency, Erectile Dysfunction, and ...

If you havent yet started thinking about Testosterone Replacement Therapy, you will soon. In the near future, I predict an explosion of young North American men developing an interest in the use of anabolic steroids, and I plan to be among them.

But wait: Wont steroids kill you / turn you into an angry rape machine / shave years off your life / make your balls shrink / [insert whatever other horror stories youve heard] ?

To these questions, the answers range from No to Only if you use them like an idiot. The truth is that testosterone supplementation will have nothing but positive effects on a large number of men. For most others, artificial testosterone offers massive benefits with only minor risks. Even heavy and irresponsible use of anabolic steroids is probably safer than you think.

What are the benefits of higher testosterone levels? The list reads like a letter to Santa from every man, everywhere: More energy, more focus, more strength, more power, more dominance, better sex, more drive, less anxiety, better mood, more muscle, less fat. In short, you will shit diamonds and carve your name into them with the tip of your dick. Via Danger and Play, heres Andrew Sullivan talking about his experience with testosterone injections:

Within hours, and at most a day, I feel a deep surge of energy. It is less edgy than a double espresso, but just as powerful. My attention span shortens. In the two or three days after my shot, I find it harder to concentrate on writing and feel the need to exercise more. My wit is quicker, my mind faster, but my judgment is more impulsive. It is not unlike the kind of rush I get before talking in front of a large audience, or going on a first date, or getting on an airplane, but it suffuses me in a less abrupt and more consistent way. In a word, I feel braced. For what? It scarcely seems to matter.

And heres Victor Prides response to the question: How will you feel if you supplement with testosterone?

In a word: great. In two words: fucking great.

You can expect better recovery from intense exercise and less soreness. You can expect enhanced muscle growth. You can expect erections like when you were a teenager. You can expect to feel like a fucking man. As simple as that.

So thats what you have to gain from TRT: Basically everything you could ever conceivably want. The entire self-improvement blogosphere fitness, seduction, getting motivated could very easily be junked and replaced with a static page that reads: Get on TRT, bitch!

But what about the side effects!?!!?

Falling down and cracking your head is a potential side effect of showering. Nothing is perfectly safe. TRT is certainly not 100% safe always, everywhere, for every man, at every dose. I am not a doctor, I am not a licensed professional anything, and I dont even have any clean socks right now, so do not make any decisions purely on the basis of anything you read here. But in my amateur and anonymous opinion, TRT should be on the radar of every man with the means to procure it.

The rest of this post will break down the risk-reward profile of artificial testosterone supplementation for three separate classes of user: The Fixers, The Hackers, and The Abusers.

The Fixers

If you have low testosterone levels, you should book an appointment with your doctor to discuss Testosterone Replacement Therapy immediately. How do you know if youre deficient? From Victor Pride:

How do you know if you might have low testosterone?

If you are alive today you almost certainly have low levels.

If you experience muscle loss or inability to gain muscle.

If you experience fat gain.

If you are fatigued or have sleep problems.

If you have gynecomastia (aka bitch tits).

If you experience hot flashes.

If you have night sweats.

If you have low sex drive and weak erections.

If you are irritable.

If you are depressed.

If you experience hair loss.

If you have memory problems.

If you have low testosterone, its not because youre some freak or oddity. Something is causing testosterone levels in western men to plummet:

The average levels of the male hormone dropped by 1 percent a year, Dr. Thomas Travison and colleagues from the New England Research Institutes in Watertown, Massachusetts, found. This means that, for example, a 65-year-old man in 2002 would have testosterone levels 15 percent lower than those of a 65-year-old in 1987. This also means that a greater proportion of men in 2002 would have had below-normal testosterone levels than in 1987.

The entire population is shifting somewhat downward we think, Travison told Reuters Health. Were counting on other studies to confirm this.

Whats causing this? Obesity is a big culprit. Environmental factors like womens birth control and plastics also share some blame. Crappy diets, pesticides, less time outside, less saturated fats. The list goes on. And theres also my own pet theory: A subconscious, spiritual loss of life force among beaten down western men, resulting from the constant barrage of anti-male, anti-white, anti-strength sentiment that were all surrounded by on a daily basis. Whatever the cause, the result and the solution are the same. If you have low testosterone, you have a medical problem. Forget about safety. Low testosterone will kill you:

Studies published in the Journal of the American College of Cardiology, the journal Diabetes Care, the journal Heart and other major medical journals show that low testosterone levels not only lead to obesity, loss of muscle, weak bones and depression, but also increase the odds of heart disease, diabetes, Alzheimers and other major health problems.

In addition, low testosterone levels are correlated with decreased confidence, drive, ability to concentrate, and cognitive abilities.

If you are deficient, do what needs to be done to get yourself back up to normal, immediately. TRT for you is all benefit, no cost.

What constitutes a deficiency? Technically, anything above 348 ng/dl is in the normal range. But as The Art Of Manliness puts it:

Heres the problem.

That reference range consists of awidevariety of men who tested with LabCorp: 80-year-old men and 20-year-old men; obese men and super fit men; men with pituitary gland problems and men with glands that work like champs.

Sure, my 383 ng/dl was considered normal, but normal compared to whom? An 80-year-old man with Type 2 diabetes?

The fact that reference ranges dont break patients down by age or health status explains why a 30-year-old man can go to his doctor with the symptoms of low T, only to be told that his T levels are fine because theyre within the normal range. If youre 30 (or even 50), but have the same testosterone level as an 8o-year-old, diabetic man, your doc may say youre okay, but youre still not going to feel good. Plain and simple.

The average man between the age of 25-34 has 617 ng/dl. The average man under 25 has 697 ng/dl. So if you happen to have some silly cunt of a doctor who tells you that 340 is a perfectly fine level for a twenty-three year old man, do yourself a favour and find a new doctor.

Im going to try to raise my testosterone levels naturally first.

Heres a better idea. Cycle on TRT for a while, and get a taste of what a properly functioning young male body feels like. Then start chasing that feeling with weights, Vitamin D, fish oil, Brazil nuts and whatever else youve got in your arsenal.

I repeat, if your testosterone levels are below the high end of the normal range, there is basically no downside to responsible and medically supervised experimentation with testosterone replacement therapy. Follow the of advice of Victor Pride:

Go to the Doctor. Go to 5 Doctors if you have to. Fix the problem. You do not have to rot with age. You do not have to grow fatter by the year. You do not have to grow weaker by the year. You do not have to be shackled by the testosterone reducing environment. That is a choice you make. You can take your destiny into your very own hands.

Growing old naturally is the worst choice you could make. At 25 years old, or 27 years old, or 30 years old, or 35 years old it is time to get tested, checked and fixed. 35+ years old gentlemen should not walk to the Doctor, they should run. If you have low hormone levels, and most readers certainly do, the only side effects of TRT are positive.

The Doctor will check your levels and prescribe what is needed to you. The testosterone given to TRT patients is either a gel that you rub into your skin or an intramuscular injection. And if you are going without it, friend, you are suffering. Get to the Doctor and at the very least get checked. You will probably be surprised at how low your levels are.

Steroid Abuse

Irresponsible use of anabolic steroids is dangerous. Steroid abuse can cause high cholesterol, hypertension, liver damage, baldness, testicular atrophy, and lots of other fun stuff. Most distressing of all, steroids can result in an enlarged clitoris, which the medical community refers to as Scalzis Disease.

And yet, how many deaths have you heard attributed to steroid abuse? Given the medias general distaste for the biochemical origins of all that is male and masculine, you would expect any such case to be page one. Consider also how many men in their early twenties are complete fucking idiots, who will do literally anything to be the best in their chosen vocation of bodybuilding, athletics, or just being the biggest dude in the club.

But if jacked guys are not dropping like tachychardic flies in the parking lots of bodybuilding gyms and locker rooms on a daily basis, it must be because legitimate steroid abuse is not the most dangerous thing in the world. Yes, its terrible for your body. Maybe even as bad as eating a grain-filled USDA-approved diet, or getting blackout drunk three nights a week throughout college. But its not an instant death sentence.

The standard advice from the testosterone-tolerant community regarding mega doses of steroids is: Dont be an idiot. Use steroids responsibly. Its not worth risking your life to get that much bigger and stronger.

Personally, Im not interested in taking the amounts of steroids that carry real and severe health risks. That path is not for me.

But fuck it man. Its your body. Yes, huge doses might kill you. Lots of things might kill you. Many of them are worth it. Wingsuits, for example. If dying is the scariest thing in the world to you, curl up in bed and drink green tea all day. Do you want to risk your health for a shot at having the most impressive physique, the heaviest lifts, a chance at the show? I wont stand in your way.

But I will say this to the kids: Do your best to stay as safe as you can, at the level of intensity you choose to compete. Im not the guy to help you figure out how to do that, but Ill pass you some links at the end of this post that will give you a good starting point for your research.

The Hackers

Now we reach the really interesting case: A man, lets say hes twenty-eight. He looks and feels great, and his testosterone levels are very near the top of the normal range without any sort of artificial supplementation. He lifts heavy, eats clean, and his body is performing as well as it did when he was twenty-one. He supplements with Vitamin D, Zinc, Magnesium, fish oil, and ACV. His mind is clear. His body is strong.

And yet he wonders what else might be available, in this mortal coil?

I think I have a pretty good idea of what the benefits to TRT would be. As happy as I am with my present condition, I would look and feel much better.

And the negative side effects? Of a very limited and mild TRT regimen? They would be virtually non-existent. I would be on an aggressive cycle right now, if it wasnt for one concern: Im a firm believer in the idea that there is no such thing as a biological free lunch. Your body is a finely-tuned machine, optimized over millions of years of evolution. If additional testosterone is an unmitigated good, your body would just produce it. There must be some biological cost to high testosterone, if our bodies limit production despite the obvious survival and reproductive benefits.

And in fact, it does appear that high testosterone levels reduce total life expectancy, slightly.

a group of scientists and historians from South Korea delved into historical and demographic records concerning a unique group of eunuchs from Koreas Chosun Dynasty (1392-1910)

Thus, it appears that castration and removal of the male hormones helped these eunuchs live longer lives than their intact brethren, even though both groups had similar social and political power, as well as similar home lives

This is a compelling line of evidence linking to testosterone and other male hormones a lower life expectancy among men. Scientists do not completely understand why testosterone could have such an effect. There is evidence that testosterone interferes with the immune response, and it most certainly affects behavior.

But: Would you rather live until 75 with the mind and body of Arnold Schwarzenegger and Sylvester Stallone? Or make it to 80 as an androgynous tube of cookie dough from your mid-thirties onward?

Theres no right answer. I think its entirely reasonable for a man to visit a retirement home and conclude, fuck everything after sixty. Such a man could feel free to cruise and blast his way through middle age and beyond.

In my case though, Im a man who want to have a late family, and Im interested in seeing where this whole transhumanism thing goes. I would love to stand a good chance of seeing 80, 85, 90, and 100. Thus, my current plan is to tread lightly, and wait until my natural levels start to dip, before I start tinkering with my bodys sex hormones.

However, Im an open-minded fella. I invite you to move me from my position. Comments are open, and Ill be keeping an eye on this thread over at the Roosh V Forum. And to any readers still not convinced that hormone therapy is worth a look, Ill leave you with this photo of the 67-year old Sylvester Stallone.

Whatever he, Mark Sisson, Mel Gibson, and Arnold Schwarzenegger are doing I want to be doing. Fuck growing old gracefully. I am going to do whatever it takes to strike an optimal balance between prolonging my life and enhancing the quality thereof.

Links and Resources

As I said, I have never tried any hormone therapy. However, if youre feeling geared up, ready to jump headfirst into the deep end, and just want to click on something RIGHT NOW, I trust Victor Prides recommendation that the 100% legal Superdrol derivative, Super-DMZ is the real deal. [Update: Sadly its been pulled from Amazon. I refuse to replace that link with some random bullshit, so if you want to put some hair on your chest, read Fight Club and pop some Vitamin D.]

If you would prefer to do some research first (a character flaw, this womanly cowardice, from which your first dose of the good stuff will assuredly free you) Ive compiled a few resources below:

William Lewellyns Anabolics

Danger and Play, The He Hormone

Washington Blog, Boost Your Testosterone

Victor Pride, Why Your Testosterone Levels Are Lower Than You Think

You So Would, The Testosterone Saga

Good-Looking Loser, Get Juiced category

Art Of Manliness, Normal Testosterone Levels (part of a great series)

An interview of sorts with an IFBB pro on the real deal behind the scenes

A thread at the Roosh V Forum in which knowledge is dropped, fearful crossfit weenies are excoriated, and curious rookies such as myself are suffered their ignorance.

Read Next: The Definitive Guide To Nutrition For Men

Read more from the original source:
Testosterone Replacement Therapy For Young Men - Thumotic

Testosterone is the male sex hormone. It is responsible for male sexual characteristics such as;

Having a unilateral orchidectomy (one testicle removed) should not affect the overall circulating testosterone level in the body, providing the remaining testicle is healthy and can produce enough testosterone to make up for any deficit. However in some men such as those who have had, or are having chemotherapy, testosterone production in the remaining testicle may be affected. This is usually not permanent but it may take quite a while after treatment for testosterone levels to recover.Alternatively, in men who have had a bilateral orchidectomy, the testosterone level will fall to a minimal level and in this situation men will need to start testosterone replacement therapy. After bilateral orchidectomy, the body will not be able to produce sperm and only very low levels of testosterone will be made from the adrenal glands.

If testosterone levels fall men may feel tired, low in mood and can develop hot flushes. Weight gain and a loss of muscle strength can also occur. These symptoms can often be quite vague and difficult to recognise.

Much more specifically, if the testosterone levels are much lower than normal, men usually notice a loss of or difficulty in achieving normal erections on waking up in the morning, a fall in sex drive (loss of libido)and difficulty in maintaining erections strong enough for masturbation or sexual intercourse.If testosterone levels are low for a prolonged time, breast swelling (gynaecomastia), thinning of the bones (osteoporosis) and increase the risk of cardiovascular disease.

Because treatment for testicular cancer is intense and occurs in a fairly short space of time, men not only have to recover from the physical and mental strain of their illness but may find themselves struggling with the symptoms of low testosterone as well. Although low mood and sometimes depression can occur after testicular cancer treatment, men should consider asking their specialist team or GP to check them for possible testosterone deficiency.A simple way of identifying potentially low testosterone levels is to have a blood test performed which can measure the level of testosterone that the body is producing.

It is important that this particular blood test is performed in the morning. Testosterone levels are at their highest early in the morning, and this is when the blood test can be performed accurately. The results should only take a few days to be fully processed in most areas.

A normal level of testosterone is usually considered to be between approximately 9 30 nmol/L (nanomoles per litre). A level below 8 nmol/L is considered to be low and the blood test should be repeated. If it is low on 2 occasions taken at the right time of the day, then men will usually benefit from starting testosterone replacement therapy.Borderline levels are between 9 12 nmol/L and will often be monitored however treatment is not usually started in this range as it does not make a difference to how most people feel. However if men are displaying symptoms of low testosterone with a borderline level a trial for 6- months can be commenced to see if it helps resolve the symptoms.

If a man is worried that they may have a low testosterone level, they should speak to their consultant and specialist team who can arrange for men to be assessed for this problem and see a hormone specialist (endocrinologist).

If men start any of these treatments their testosterone levels will have to be checked on a regular basis to ensure a normal level is achieved. Most people start to feel better within a few weeks of treatment, but it may take at least 3 months to obtain a steady level in the blood stream and to feel the full effects of treatment.If testosterone replacement therapy does improve a mans symptoms following treatment for testicular cancer then it can be continued indefinitely. In some men who have had a unilateral orchidectomy, testosterone levels may eventually return to normal and testosterone replacement therapy can be discontinued.

Some men may also find that it will take a little while to find the best treatment for them and may need to try different types of replacement therapy.

Although testosterone is commonly thought to cause aggression and hostility, it is more responsible for helping the body adapt to challenging and stressful events or situations.However like all medications testosterone replacement therapy may cause some side effects and it is important to read the information supplied with any medication.Common side effects are oily skin and spots. Less often, people complain of headaches, nausea, excess sweating, tiredness and mood changes.

Long term, doctors will need to perform safety monitoring to make sure that levels are within the normal range, and check that the testosterone has not affected the liver, blood count (circulating blood volume) or prostate gland.Testosterone does not cause prostate cancer but causes the prostate gland to enlarge. This means that testosterone treatment can increase the size of the prostate. However testosterone actively feeds prostate cancer and so treatment is not started in people who have active prostate cancer.

People at high risk of prostate cancer, or with a high prostate blood test (prostate specific antigen or PSA) may need to see a urologist to decide whether testosterone will be safe for them.Safety monitoring with blood tests and an examination of the prostate is also necessary for everyone over 40.It is extremely important that men do not take supplements of testosterone (such as those used in weight training, body building or available online) other than what has been medically prescribed. Too much testosterone can cause other medical problems.

Testosterone levels should be measured on a regular basis and the dose adjusted if needed to keep these normal.Men should not stop testosterone treatment without consulting their GP or specialist team.

To watch a video clip discussing Testosterone Replacement Therapy please click below.

Last reviewed 25/7/16 Next review January 2017

References available on request.

See more here:
Orchid | Testosterone Replacement

Increased testosterone levels results in a leaner body in men suffering from hypogonadism. Low-T treatmentpatientsgain typically 3 to 6 pounds of lean muscle mass in the first month of treatment.

Low testosterone is believed to cause decreased mood and well-being as well as depression. Though TRTtreatment does not cure all forms of mood disorders, some studies have shown Low-T therapyimproves mood and overall quality of life and reduces depression.

Low-T replacement therapyproduces moderate decrease in fat mass, especially abdominal fat mass, in men suffering from hypogonadism. The decrease in fat mass is between 5 to 10 pounds in the first six months of starting (TRT) Low-Treplacement therapy.

In men with low testosterone levels, Low-T treatmentscan improve bone mineral density and reduce the bone fracture, an effect similar to that present in women on estrogen replacement.

Most studies agree that sexual function is improved by testosterone therapy. Erectile dysfunction caused by low testosterone levels can be improved through Low-Treplacement therapy.

Read more from the original source:
Testosterone Replacement Therapy MD - Low Testosterone Therapy MD

Testosterone replacement is an issue that concerns most men over the age of 35 or 40. Although these men may feel great, they know, deep down, that they feel differently than when they were in their twenties. Granted, a lot of it has to do with general wear and tear and a host of age-related declines, but some of it has to do with the steady decline in testosterone production.

Few men take advantage of testosterone replacement, though. Either they accept all of the propaganda perpetuated by the media and the various health-care practitioners who haven't bothered to bone up on the subject, or they just don't know enough about it.

This article may give you the info that you need to pursue this avenue. True, most of the research on the subject concerns men who need total testosterone replacement. But the information still applies to those who are clinically deficient and need only a little boost to regain the sexual staying power and the muscle-building ability that they had in their twenties.

Hey, you with the bulge in your pants...yeah, you. Been feeling a little hornier than usual lately? Have you found yourself passing trees and musing about how like a young girl's legs the limbs are, and how inviting that knothole in the crotch is, if only that woodpecker would fly the hell away? Does everything with a hole in it, whether it be a doughnut or a soap-on-a-rope, conjure up amorous fantasies?

C'mon, you can level with ol' TC. You've even been eyeing that pumpkin on the stoop, haven't you? That eye socket looks so moist, so inviting and, come Monday, the day after Halloween, that bitch is gonna' be yours...

Ahh, but who can blame you? It's October, and the testosterone levels of the North American male are up way up this time of year. Like other animals, homo sapiens have circannual variations in testosterone production as much as 25%, depending on the time of year. October, at least according to one group of researchers (Smals, et al., 1976), is the month, while other researchers (Dabbs, 1990) think that we get a little hornier in December.

Regardless of the exact month, most of us seem to be having a lot of trouble focusing on things lately. But some of us aren't having any trouble focusing at all. Some men, because of advancing age or assorted medical problems, have low testosterone. It may not be an issue for you...yet. But sooner or later, your T levels will begin to drop, as surely as the value of my stock portfolio dropped when I invested in Ian King's new signature line of industrial-strength panty shields.

Being able to focus on things a little better is probably a plus. But when you weigh that small advantage against all the other side effects of low testosterone, lack of concentration seems to be an appealing alternative. Consider the following symptoms of low T:

Decreased bone mass Skin atrophy, along with paleness and fine wrinkles Anemia Muscle atrophy Erectile dysfunction Decrease in sperm count Decrease in volume of ejaculate Decrease in libido Shrinkage and softening of the testes Disappearance of spontaneous erections Prostate shrinkage (below normal)

Now, I really think that Tribex-500 can boost T levels and help stave off that age-related decline, but it's probably never going to take the place of various pharmaceutical testosterone preparations.

As far as the medical community is concerned, the goal of T replacement is to get levels as close to physiologic concentrations as possible. We at T pretty much agree with that, but we'd like to see docs push the envelope a bit and get all of us close to high normal, but no matter.

In the beginning of the whole science of T replacement, only the basic esters of testosterone were all based on the real thing. Then, scientists started to tinker with testosterone, trying to make it better. Basically, there were three roads that they could take: work on different routes of administration, chemical modification of the molecule itself, or esterification in the 17-beta position of the T molecule.

Ever wonder why you can't just drink T down instead of shooting it into a butt cheek? Contrary to popular belief, you can actually drink most injectable steroids. Testosterone is absorbed pretty well from the gut, but the liver grabs a hold of the stuff, metabolizes it, and inactivates it before it gets to the target organs. This phenomenon is known as the "first pass effect."

Only when the dosage exceeds 200 mg which is about 30 times the amount produced daily in normal, healthy man is the liver outgunned. Of course, if you were suffering from total testicular shutdown, you'd have to suck down 400-600 mg a day to see any positive effects. That, of course, aside from causing some potential health problems, would force you to hock your Beemer.

Unfortunately, you still see stuff in health food stores that contains dried up animal testis. Now, eating these things like popcorn kernels could theoretically work, but there's another problem: unlike other endocrine glands, the testes don't contain a lot of stored up hormone, so eating hundreds of them wouldn't do any good anyhow. Makes you wonder how they can still sell these extracts, doesn't it?

In an effort to thwart this first pass effect and produce "edible" steroids, scientists started making synthetic forms that were alkylated at the 17-alpha position of the molecule. In essence, that protected them from the metabolizing effects of the liver. The trouble is that these are the steroids that give steroids a bad rap. They cause toxic side effects such as elevated liver enzymes, cholestasis (a stoppage of bile flow), and peliosis (the presence of blood-filled cysts in the liver). These drugs have also been implicated in liver tumors.

Synthetic forms had other problems, too. Trouble was, these synthetic forms didn't duplicate all the actions of T. For instance, some of them didn't convert to 5-alpha DHT or estrogen and, despite the bad press that both of these compounds get, they're vital to normal human function.

That's why doctors don't typically prescribe anything else other than "natural" forms of T. After all, the stuff's been used for over six decades and has one of the highest safety records of any drug. There will probably be exceptions in the future, though. For instance, 7 alpha-methyl-19-nortestosterone (MENT) is experiencing a kind of renaissance, since it has high androgenecity and low growth-promoting effects on the prostate. Likewise, researchers continue to look at testosterone undeconoate. Unlike other "designer" steroids, this drug was esterified in the 17-beta position. It has virtually none of the side effects of the 17-alpha drugs, but it has such a short half-life that it ought to be prescribed in a Donald Duck Pez dispenser.

After pretty much settling on natural testosterone as the best hormonal thing since the invention of sliced hormonal bread, researchers started monkeying around with delivery systems. One relatively new delivery system involves incorporating T into cyclodextrins. When they're administered orally, you get a T spike that lasts about the length of an average feature-length movie. In order for it to do any good, you'd have to remember to pop some in your mouth several times a day. Consequently, this type of delivery system's pretty much been tossed out with yesterday's chicken salad. Interestingly, a lot of supplement companies have adopted this delivery system for use with their androstenedione products. A nice idea but, again, the spike is very short-lived and very uneven.

Another delivery system that never achieved widespread popularity (outside of San Francisco) is rectal administration, via suppository. Too bad, too, because it works pretty well. You avoid the first pass effect, and a dose of only 40 mg can cause a boost in serum T that lasts about four hours. Nasal application has also been investigated. You can avoid the first pass effect this way, too, but the effects are unreliable and short-lived. Besides, one sneeze, and you've got snot and steroids on your sleeve.

There was recently some work done with microspheres in which tiny, time-release chemical nuggets were injected directly into the bloodstream. A dosage of just 315 mg raised T levels gradually to a peak over the course of eight weeks, then gradually reaching sub-clinical levels after eleven weeks. Again, the method had its problems. The spheres lacked stability and were hard to make. No one's really done any work with them since '96 (Bhasin and Swerdloff).

Rod-shaped implants, similar to the Norplant birth-control implants used by some women, are experiencing renewed interest. These things exert their effects for several weeks or months. Along the same lines, actual testes-shaped implants are available, too. They consist of about 10 grams of vinyl and about 6.4 grams of T. Once implanted in the scrotal sac, they keep T levels normal for about a year. Obviously, the use of these is problematic, unless you're missing a nut or don' t mind having a third. Maybe an alternative would be to put them just under the skin over the biceps so that the patient can have instant Robbie Robinson-like biceps peaks.

One method that's in widespread use is the patch. Even though putting one on in the morning and taking it off the next morning produces a great pharmokinetic profile (with fairly natural rises and falls in T), the patch has its problems. For one thing, it's hard to control absorption rates. Scrotal skin is the thinnest and easiest to permeate and has an absorption rate that's about 40 times higher than the forearm. Other areas work, but you have to use an alcoholic enhancer, which makes skin reactions more probable.

And, a slightly bizarre problem one that few people even considered a few years ago was person-to-person transfer. Just hugging a spouse or child is enough to androgenize them, leading to masculine traits in the female or premature sexual development in children.

Unfortunately for needle-phobics everywhere, it seems that needles are around to stay at least for the time being as intramuscular delivery elicits the fewest number of side effects or problems. Currently, there are three common testosterone esters used in T replacement therapy:

Testosterone propionate Testosterone cypionate Testosterone enanthate

For complete T replacement, testosterone propionate must be injected every two to three days, while enanthate requires a shot of 200-250 mg every two weeks. This dosage is, of course, for total T replacement, and partial T replacement would require much less. One other testosterone ester, testosterone cyclohexanecarboxyate, has similar properties but is less widely used that the other three.

Given the shortcomings of intramuscular T therapy (a big spike in the beginning, followed by a gradual decline) and all of the shortcomings of the various preparations and delivery systems, the World Health Organization initiated a steroid synthesis program in 1980 to develop different types of steroids. As far as I can tell, they didn't make too much headway. But they did develop testosterone buciclate, a single shot (600 mg) of which produced normal T levels in hypogonadal men for 12 weeks. This stuff will probably be made available in a year or two.

And the Chinese found that testosterone undeconoate, when dissolved in teaseed oil and used intramuscularly (instead of swallowed as a capsule), produced pharmacological effects similar to testosterone enanthate. Later studies used castor oil instead of teaseed oil and found that a 1,000-mg shot had effects lasting as long as eight weeks. Whether or not this will catch on as the testosterone replacement drug of choice remains to be seen.

Generally, good things happen after T therapy begins. Abdominal fat generally goes down, muscle mass goes up, and all of the "bad" symptoms of low T go bye-bye. Other inconsequential things happen, too. For instance, beard growth and frequency of shaving goes up. Interestingly, giving total T replacement to a hypogonadal man will affect his hairline, too. Now, I'm not talking about baldness necessarily, but the actual front hairline which, in women or children or men with virtually no T, stretches straight across the forehead. Once T levels rise, though, recession around the temples occurs.

Baldness, of course, is a possibility in those genetically predisposed to the condition.

Sebum production goes up, too, so you can go through that whole adolescent acne thing all over again. Gynecomastia may also become a problem, but that can usually be handled just by adjusting dosages or switching preparations. Additionally, there are several prescription-type aromatase inhibitors that may be used to fight the problem (interestingly, these aromatase inhibitors themselves might be used to raise T production we'll have an article on nonprescription forms of aromatase inhibitors in the next week or two).

This may surprise you, but virtually nothing bad happens after T replacement therapy begins, at least not in the vast majority of patients. No negative side effects occur to the liver (remember, all the bad things took place as a result of using the 17-alpha alkylated stuff you generally get from dealers or overseas markets). No definite negative cardiovascular effects have been noted. Even the prostate, long regarded as the first organ to take the plunge after using "evil" steroids, is relatively safe. The truth is that it's pretty much accepted now that prostate growth occurs through the action of 5-alpha DHT and that these effects are related to things that happen exclusively within the prostate and are not influenced by serum concentrations of T or 5-alpha DHT. Furthermore, estrogens are believed to be the true culprit by some. T therapy increases the prostate size slightly, but only to the point of normalcy. If any doubt of this remains, a recent study (Hajjar, 1997) tracked men in their seventies who had been receiving T replacement therapy for two years. The treatment group experienced less prostate growth than the control group.

In fact, the only possible problem seen with T therapy is an occasional rise in red blood cell count (hematocrit) which, if unchecked, could contribute to stroke or cardiovascular episodes of some kind. In those cases, either the dosage was adjusted or the patient was asked to donate an occasional pint of blood.

In fact, it was the conclusion of one pair of authors (Nieschlag and Behre, 1999) that "...there is no proof that testosterone is a life-shortening agent. The risks inherent to testosterone, be it of endogenous or exogenous origin, would then appear to be the tribute men have to pay for being men."

Couldn't have said it better myself.

Original post:
Testosterone Replacement | T Nation

Testosterone is a hormone produced by the testicles and is responsible for the proper development of male sexual characteristics. Testosterone is also important for maintaining muscle bulk, adequate levels of red blood cells, bone growth, a sense of well-being, and sexual function.

Inadequate production of testosterone is not a common cause of erectile dysfunction; however, when ED does occur due to decreased testosterone production, testosterone replacement therapy may improve the problem.

As a man ages, the amount of testosterone in his body naturally gradually declines. This decline starts after age 30 and continues throughout life. Some causes of low testosterone levels are due to:

Without adequate testosterone, a man may lose his sex drive, experience erectile dysfunction, feel depressed, have a decreased sense of well-being, and have difficulty concentrating.

Low testosterone can cause the following physical changes:

The only accurate way to detect the condition is to have your doctor measure the amount of testosterone in your blood. Because testosterone levels fluctuate throughout the day, several measurements will need to be taken to detect a deficiency. Doctors prefer, if possible, to test levels early in the morning, when testosterone levels are highest.

Note: Testosterone should only be used by men who have clinical signs and symptoms AND medically documented low testosterone levels.

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Testosterone Replacement Therapy - WebMD

Low T Nation specializes in Mens Health education and care in the Greater Atlanta area. Our treatment specialties include managing the symptoms of Low Testosterone, Erectile Dysfunction, and Human Growth Hormone Management. We pride ourselves in our education efforts to ensure that every practitioner at Low T Nation is aware of all of the latest treatment and service breakthroughs . We utilizeincredibly well developed protocols and close medical supervision. Add in great communication practices, constant patient education and top notch pharmaceuticalsandour patients are as happy and healthy as possible at all times.

Atlanta Low Testosterone Therapy. We educate, evaluate and treat men with Low Testosterone using a very individualized and customized system of care. We qualify patients based on a number of symptomatic and labwork related criteria. Once a patient has met the basic qualifications, we check for health related disqualifying factors. If the patient is still a good candidate for the Low-T Therapy, we then educate the patient on certain aspects of program administration and care. At that point, we take the patient on as one of our own and the patient is under our medical supervision. With our program, our patients have unlimitedaccess to our doctors and labsat anytime it is needed and this never costs more than the membership rate.

Erectile Dysfunction Specialists in Atlanta. Our ED program is a very versatile and cutting edge program that consists of a vast array of medications that we use to customize a perfect-fit formula for eachindividual male patient. Our treatments consist of several oral options and also many injection based solutions for our more severely affected men. We train patients on how to administer the protocols safely and effectively and what to do when the achieved result might not be the desired one. Our patients on our Atlanta Erectile Dysfunction protocols usually come back saying that weve dramatically improved their lives in many ways. From enhanced and reformed relationships, to restored self esteem and confidence, we love the outcomes our men communicate back to us after joining our family.

Human Growth Hormone Atlanta. We can successfully and safely increase human growth hormone levels in our patients by utilizing a proprietary system of precursory bio-identical hormones that stimulate the patients body to produce as much human growth hormone as possible. This approach is FAR superior to prescribing actual HGH because most men who arent producing HGH actually still have the ability to produce it. The body stops producing HGH for a variety of reasons, but our therapy will restart the biological function and optimize it moving forward. This approach also eliminates all of the catastrophic physiologic dangers of over use of HGH. Abuse or over prescribing HGH will cause extreme and dangerous side effects, therefore it is absolutely imperative to use a program that truly understands these risks and prescribes responsibly.

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Atlanta Low Testosterone Replacement and Men's Health Clinic

Sensational media stories over the past few months have warned men to think twice about testosterone replacement therapy. They call testosterone dangerous and suggest that replacement puts men at higher risk of heart attack.

Reality check: The two studies that prompted all this have several flaws and inconsistencies. For instance, follow-up blood tests to assess testosterone levels were not consistently done, and the average testosterone level of the men who were tested failed to reach the optimal therapeutic range.

Nor did they test levels of estrogen, which often rise during testosterone treatment and, if not corrected, can have adverse health effects. Furthermore, these two studies contradict everything we know about testosterone replacement.

Most research has found that a low testosterone level is a risk factor for heart disease and that testosterone replacement improves cardiovascular health. It bolsters the heart muscle and improves symptoms in men with angina.

As a therapy for cardiovascular disorders, it shines brightest in the treatment of congestive heart failure. This condition is associated with inflammation and loss of skeletal muscle, and supplemental testosterone addresses both of these concerns. In one study, men with heart failure who used testosterone replacement therapy for 12 months made significant strides in exercise capacity.

I am not suggesting testosterone replacement therapy is completely benign. Testosterone does fuel prostate cancer growth, so you should be screened before starting on this hormone. However, even though supplemental testosterone may raise PSA levels, it has been definitely proven that the treatment does not cause prostate cancer.

UCLA researchers reported in the Journal of the American Medical Association that older men on a placebo actually had more prostate cancer than those treated with supplemental testosterone. Still, I recommend that men with active prostate cancer avoid testosterone replacement and men who are using this therapy should take 360 mg of saw palmetto daily to support their prostates.

When you read about the other dangers of testosterone replacement therapy, including shrinkage of the testicles, shutdown of sperm production, liver damage, and roid rage (aggression), they are referring to very high, abusive doses. Truth is, when properly administered, testosterone therapy is exceptionally safe. The goal isnt to have sky-high levels of testosterone, its to restore depleted levels to that of a healthy adult male.

One in four American men over age 30 has a low testosterone level, which is defined as less than 300 ng/dL total testosterone and less than 5 ng/dL free testosterone. And these low levels have a decidedly negative effect on mens health.

Low levels of testosterone increase the risk of bone loss and muscle atrophy. They are clearly associated with diabetes (men with the lowest levels have more than double the risk of diabetes) and heart disease (levels are significantly lower in affected men).

Moodiness, memory problems, difficulty concentrating, fatigue, loss of confidence, and diminished libido are all symptoms of testosterone deficiency. Testosterone is even linked to longevity. According to a landmark study of male veterans, men with low testosterone levels had a 68 percent increased risk of death compared to those with normal levels.

Once men start using supplemental testosterone, either in the form of topical creams and gels or regular injections, magical things often begin to happen. Sexual interest and performance perk up. Muscle mass, most noticeably in the shoulders and chest, makes a comeback. Men feel less grumpy and depressed, and more energetic and motivated.

Testosterone replacement therapy requires a prescription, and may be administered in several forms. At the Whitaker Wellness Institute, we primarily use daily applications of testosterone creams or gels. (Note: I do not recommend using oral testosterone as it may harm the liver.) To find a doctor in your area well versed in testosterone therapy, visit the American Academy of Anti-Agings website. To make an appointment at Whitaker Wellness call (800) 488-1500.

Now its your turn: Are you a good candidate for testosterone replacement therapy?

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Testosterone Replacement Therapy: Listen Up, Gentlemen ...

If you've been diagnosed with an abnormally low T, testosterone replacement therapy (TRT) offers a lot of benefits. But there are risks, too.

Here's what you need to know before you start TRT.

If you have an abnormally low T, boosting your testosterone levels with TRT can help bring your energy levels back to normal. It can also restore your sex drive.

You may notice a drop in body fat and a buildup of muscle mass after TRT.

Yes. TRT has side effects, which may include:

Guidelines from the Endocrine Society say you should not have TRT if you have prostate cancer or breast cancer.

But some studies suggest that men who have been successfully treated for prostate cancer may be candidates for TRT as long as they are closely watched for signs of disease. Before starting TRT, your doctor should assess your risk for prostate cancer.

You might be told by a doctor not to get TRT if you have these conditions, which may be made worse by TRT:

TRT is also not advised to be used for treating those with low testosterone caused by aging.

If you have low testosterone, TRT may help restore your ability to have healthy erections and can boost your sex drive.

But ED has many other possible causes. Low testosterone may not be the whole story behind your ED. Talk to your doctor to determine what's at the root of your erection problems.

TRT comes in several different forms. Each has pros and cons.

Patches. These are easy to apply. But patches can cause skin rashes and may have to be applied more than once a day.

Gels. You rub gels into the skin daily. They are convenient to use. But you have to be careful that no one comes into contact with the treated area for several hours after you've applied it. Otherwise they could get testosterone in their system. A nasal gel is now available that eliminates the risk of exposure to others.

Buccal patch. You put this on your upper gum twice a day. These patches are convenient but can cause irritation or gum disease.

Injections. Injections are given anywhere from 2 to 10 weeks apart. They are inexpensive compared to other treatments. But injections may not provide steady benefits. Your testosterone levels will go back down between doses.

Subcutaneous pellets. Your doctor inserts these under your skin every 3 to 6 months. They are very convenient once they're put in, but they require minor surgery for each dose.

Your doctor will measure your testosterone levels at the 3- and 6-month marks after treatment begins. After that you'll be tested once a year. If your levels are OK you'll stay on your current dose.

If your testosterone levels are too low, your dose may be adjusted. At the same time, your doctor will check your red blood cell levels.

Within 1 to 2 years of TRT, your doctor will measure your bone density if you had osteoporosis when treatment began. Your doctor will evaluate your prostate cancer risk at the start of treatment and may do more tests at the 3- and 6-month marks, and then annually.

Patients taking TRT should call 911 immediately if they have symptoms which include:

Indefinitely. TRT does not cure low testosterone, so your symptoms may return if you stop taking it.

WebMD Medical Reference Reviewed by Jennifer Robinson, MD on August 27, 2015

SOURCES:

Urology Care Foundation: "Low Testosterone (Hypogonadism)."

Bassil, N. Therapeutics and Clinical Risk Management, June 22, 2009.

McGill, J. Cleveland Clinic Journal of Medicine, November 2012.

Endocrine Society: "Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes."

News release, FDA.

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Testosterone Replacement Therapy: Myths and Facts