Is it Low Testosterone or Natural Aging

thanks for coming tonight my name is John Ludlow I'm one of the neurologists at Western Michigan neurological Associates which is part of Holland Hospital and lakeshore Health Partners and I'm going to talk tonight about testosterone and testosterone replacement therapy you know we've heard a lot about testosterone in the media over the past five or six years and it's a topic that is is popular it needs to be discussed there's a lot of myths there's a lot of misinformation and I think it's something that that is important not only from the standpoint of urology but in from the standpoint of general men's health you know I think one of the things about men's health men have a tendency to not want to go to the doctor and to keep themselves healthy women on the other hand are sort of interesting they go through their OBGYN and they maintain a sort of a regular health maintenance program through their earlier years we sort of tread through things until we're 50 or 60 and start to have some problems and then find her way to the doctor usually as in my case my wife is grabbing me by the back of the neck and telling me to go to the doctor but keeping ourselves healthy is an incredibly important thing and it's not something that we've done is physicians you know we treat disease we don't prevent disease but we should prevent disease and I think testosterone is one of those things that plays a role in prevention of disease and maintenance of health so I'm going to talk about testosterone in general and go through a discussion here well I think one of the one of the ways that that we can most benefit from a discussion like that is to keep it a discussion meaning the questions ask questions I don't need to run through 40 or 50 slides and people raise their hand if you have a question while I'm talking about things raise your hand and ask the question I'll tell you what I learned from you guys so and everybody else learns from your questions so ask questions I think it's really an important part of this whole discussion let's look let's keep it so what are the important men's health issues in 2015 Dietary health health maintenance diet is incredibly important keeping ourselves healthy cardiovascular health obviously keeping our heart and our vascular system healthy bone and joint health PSA and prostate cancer a lot of discussion about PSA and the utility of PSA and whether we should get PSA so I think PSA is very important prostate cancer is an interesting disease yeah go ahead PSA is good question what is PSA PSA is prostate specific antigen it's a blood test that helps us screen for prostate cancer there are controversies about whether we should even be getting PSAs and I will tell you flat-out that we overdiagnosis and overtreatment to the patient's detriment the flip side of that story is that 30,000 men will die will die from prostate cancer at this disease this year and the men that are dying from prostate cancer aren't going to tell me that they were over over diagnosed or over treated we have a lot to learn about prostate cancer and understanding prostate cancer and it's a topic that is on the front burner for us and we should we should focus on that as well in future discussions that's what we're gonna do yeah yeah the question is should men on a yearly basis have a prostate exam and I'd answer that in the following way when I was in training down in Indiana University which is a big urological Cancer Center it's one of the biggest in the country one of the professor's I learned from said to me the only person that doesn't need a rectal exam is the person that doesn't have a rectum so that's how I'm gonna answer your question it doesn't hurt to do it that much it's a little uncomfortable but I'll tell you what I examine everybody on a yearly basis but I'm very good about making sure that I'm doing the right thing and talking to them about other options when it comes to abnormal exams or the PSA blood test for example so I would tell you yes you need a yearly rectal exam whether you need a yearly blood test for a PSA is a discussion that you need to have with your physician it comes with some controversy that's a good question benign prostatic disease benign prostatic disease is simply we have give our prostates grow we have some difficulties urinating erectile dysfunction and we sort of look at that and we say wait a minute its erectile dysfunctions not that big of a deal erectile dysfunction is a big deal erectile dysfunction is a vascular disease in most cases very much like heart disease as a vascular disease that heart attack is a vascular disease stroke is a vascular disease erectile dysfunction just occurs before all those other other things occur so when I hear men 40-year old men with vascular erectile dysfunction I tell them flat out their higher risk of heart attack and stroke and I can tell you I've saved a few people's lives because we've talked about their erectile dysfunction and we focused on that so it's not a trivial issue by any means it's something we need to discuss and then finally testosterone which is what we're going to talk about tonight so what's the big deal with testosterone testosterone is a big deal we know that testosterone has direct and indirect effects in almost every organ system in the body hypogonadism that's low testosterone hypogonadism is the technical term for low testosterone it's a crucial factor in patients with chronic disease states heart disease pulmonary disease different types of types of vascular disease liver disease low testosterone is very important in those disease processes shifting demographics what does that mean shifting demographics is is the increase in the number of people over the age of 65 basically the baby boomers are getting older and getting the higher in number and baby boomers don't want to sit around and and put their feet up and watch TV we want to live our lives and do the things we want to do and testosterone can can play a role in that and the bottom line with with this shifting demographics is that I'm seeing more and more patient at older and older ages who want to live their lives and do the things they want to do and this shifting demographics is important patients that are that are coming into my office we know that five million men in the u.s. are affected by low testosterone benefits of treatment can be significant there is the issue of risks and I put a question mark there because we don't really know all the risks of testosterone replacement and I will tell you that there are a stack of peer-reviewed journal papers that support the use of testosterone and the benefits of testosterone replacement therapy and there are about three or four papers that would suggest there are downsides to testosterone replacement therapy and none of those papers carry any weight and in my mind so we still have some issues with risk it's something we need to think about and discuss but I would tell you that the benefits far outweigh the risks it's a good question it's a good question the question is a study came out a year and a half ago or so that talked about testosterone replacement and increase in the risk of heart attack and stroke there were two studies one study was from the VA and if you look at that study first of all I would tell you that there are 30 medical societies in the United States that wrote to the American Medical Association and demanded retraction of the paper this paper was in the Journal of the American Medical Association if you look at the statistics there were there were incorrect and and and significant errors in the statistics and if you look at the statistics really what they showed was that there was a 50% reduction in heart attack and stroke in men who were treated with testosterone replacement so those papers the two or three or four papers that that we've seen have significant flaws and errors and none of us think that they're important or significant but it's a it's a good question four to five million men and then in the United States have low testosterone it's a significant disease process actually this number is probably low it's probably closer to eight to nine million men so it's not an insignificant issue what I'm going to talk about tonight specifically I'm going to talk about the regulation and physiology of testosterone secretion how do we get testosterone in our bloodstream I'm going to talk about testosterone deficiency in chronic disease states we're gonna focus on this thing called the metabolic syndrome which is important and we're seeing more metabolic syndrome in this country and I'll talk about that we're going to talk about testosterone replacement therapy and prostate cancer testosterone replacement therapy in the aging male as a effect sexual function and then the options in testosterone replacement therapy so this is the physiology of testosterone comes from cholesterol so if you think you don't need cholesterol you're wrong you need cholesterol cholesterol is a good thing too much of it is not a good thing but cholesterol is a good thing and cholesterol gets changed through all these different things and it becomes testosterone and then in the male a small amount of testosterone gets converted to estradiol which is the female hormone you don't want too much of that but you want some of it because estradiol is important to our our bone health and if if you get too much estradiol other bad things can happen but you do need a little of it just like women need a little testosterone as well as far as cholesterol in HDL do those are different forms all I'm talking about is is the the compound test cholesterol that's all that it matters and cholesterol gets converted in the liver to those different substances we know that testosterone is the primary circulating androgen and by androgen we mean the substance that helps us build up our muscles and our bones and some other things this these substances gets secreted in the brain they go to these substances in the testicle and testosterones secreted by those cells the adrenal gland which is a small little plant on top of the kidney contributes about 5 percent of overall testosterone we know that testosterone is style and dye your own meaning that it gets secreted in sort of a rhythmic fashion and that has a consequence as far as testosterone replacement because if you come into my office and I give you a shot and you get a big burst of testosterone and it trickles down over two weeks that's not necessarily a good physiologic way to replace testosterone the problem is it's a good way to do it from this from the insurance company's standpoint it's the cheapest way to do it and that's how the insurance companies want us to do it I don't like it but it's maybe the best thing we have and when you talk about finances and dollars and cents in healthcare we're not talking about little numbers yes there's a there's a the question is the shot is one way to replace testosterone what are the other ways I'll get into that I'll go through that very specifically toward a little bit deeper in the talk we know that the highest concentrations of testosterone occur in the morning and we know that when we measure testosterone in the bloodstream it's not all the same there's some of that testosterone is is bound to other things and doesn't work some is partially bound in can work some is unbound and is very active and it's different different people and so I can't in many cases just look at a total testosterone and say this is what you have I have to look at some other things as well understanding how to draw testosterone measure testosterone and interpret testosterone is really an important issue so this is just testosterone in our body more or less this is the hypothalamus which is a part of the brain that secretes this substance that goes to this part of the brain called the pituitary that secretes luteinizing hormone that goes to the testicles and makes testosterone and that's sort of the simplistic way to look at it but it's much more complicated than that and it's it is a very complicated process so how does testosterone work it works in a couple of different ways number one we can have what's called free testosterone which is really the testosterone compound circulating in our bloodstream that gets incorporated into cells and does things to the nucleus or the of the cell the other way it can be converted converted to this substance called dihydrotestosterone which is really very very important and that can be the more functional aspect what's important about dihydrotestosterone or DHT is that when I removed your prostate I take away your ability to make DHT and in the past we didn't think that was important but it is important the same thing happens when I irradiated prostate for prostate cancer and I can give you some medications that can inhibit the the manufacture of DHT understanding DHT is important is becoming much more important there are some good studies done at the University of California San Francisco looking at DHT and understanding what DHT does for us when we really used to ignore it and now we're really focusing on it a lot of question marks with DHT so it's it's something that's on the front burner right now and then finally estradiol which again is that female hormone which supports bone health and really it's said that's an important substance as well this is more of a complicated thing this basically talks about how testosterone works and what it does to us it's got to get incorporated into cells so it attaches itself to the cell out here and it gets incorporated into the cell and does complex things to the inside of the cell which alters the way certain cells function and I'm talking about your brain your liver your bones your muscles your heart your vascular tissues your erectile tissues virtually all that all the tissues in your body and all of those are important so that's a little bit more complicated but the testosterones got to get into those blood cells one way or the other so the direct effect of testosterone that's how testosterone interacts with a muscle or with a bone or with other parts of the body it has direct effects on muscle mass on bone formation on our ability to make sperm and on sexual function as well as other parts of the body as well and again this DHT although we talk about things like so on body hair and scalp loss baldness prostate and erectile dysfunction and acne we're finding that DHT does much more than just this and it's becoming something that we're focusing on much much more and finally estradiol again I really focus on bone health and atherosclerosis those are really important if we don't if we're converting testosterone to the to estradiol we're seeing more significant problems in bone health and let's talk about bone health for a second somebody that falls and breaks their hip in their 80s has a significant mortality rate death rate from that fracture and what we know is that men in their 80s have lower testosterone levels and consequently lower estradiol levels so bone health is incredibly important in the consequences of poor bone structure and strength can be significant it's not a trivial disease so let's talk about circulating testosterone this is testosterone that's in our bloodstream and it really comes in two forms a bound form and that's the form that has the ability to function I'm sorry the the bound form has the ability is as no ability to function and the unbound form meaning the free testosterone so we know that sex hormone binding globulin and albumin will both bind testosterone if testosterone is bound to this sex hormone binding globulin it's not working at all so if I measure your total testosterone and comes back 330 and you have an elevated sex hormone binding globulin you probably have a very low testosterone level so understanding how to measure this and how to interpret this is important albumin is a little bit different when albumin binds testosterone it does it in somewhat of a reversible manner so it at times will be bound in times will be unbound and in many cases I'll look at patients albumin levels as well to get an idea of what their free testosterone actually is so what we refer to as the bio-available testosterone is really the unbound and the albumin bound the bottom line is that when I measure testosterone and it comes back equivocal meaning it's in that middle range there I really want to know what the unbound and the albumen bound is before I make decisions we also know that there are certain disease states thyroid disease obesity some other liver related problems that elevate sex hormone-binding globulin and then consequently lower testosterone levels although when you measure them they can still look normal so it can be it can be complicated you can't just look at that number and say that's normal or that's abnormal you have to think of the patient in the hole and it makes it a little bit more complicated yeah the question is is is there a separate test for the bound and unbound and there there can be if I measure a total testosterone in somebody and it comes back 150 as an example and I'll go into this a little bit later that's abnormal regardless of your albumin or your sex hormone binding globulin but if it's in that middle range where you're maybe just a little bit above normal or in that equivocal range which we say between 300 and 350 then I want to do some more investigating to figure out whether there's an elevated sex hormone binding globulin what the albumin looks like and I can calculate the free and the total testosterone that way so there are certain ways that you can do that you have to have a good relationship with the lab I've got to be able to talk to the lab and and understand what they're measuring when I when I look at those equivocal numbers this again just represents the the total testosterone we know that about 60% is is pretty tightly bound to sex hormone binding globulin 30:38 to 40% to albumin and about 2% is free and that changes depending on disease states and some other other issues so let's talk about measuring testosterone timing is important and we've gone back and forth over this do you do it first thing in the morning do you do it fasting can you do it anytime The Endocrine Society came out with some guidelines and the guidelines state right that you have to fast from midnight the night before and preferably draw the testosterone level between about 9 and 11 o'clock in the morning and if we all go by those rules we're going to be able to reach some consistency in determining who has low testosterone and who doesn't so I'm pretty good about making sure that that's what we're doing and that can be a convenience issue as well people work people work different shifts and sometimes that's not possible to fast from midnight and to get the blood drawn in the morning but that's the typical rule at this point in time again testosterone may be affected by sex hormone binding globulin there's this thing called equal equilibrium dialysis this is something that's of interest only in in certain scientific studies no lab spectrum is not going to do it the Mayo Clinic is not going to do it there are specialized labs there's one at UCLA in Los Angeles that will do this there's one at Harvard in Boston there's one down in Texas where we can actually measure the free testosterone that free portion most often what I'm looking at that I'm going to do that look at the free testosterone in a calculated manner these are some other assays that look at total testosterone and again these enter current society guidelines are incredibly important and I follow them to the tee and I think we all should all of us that are that are seeing patients with low testosterone and evaluating them and recommending treatment to them should follow these guidelines one of the questionnaires that we have used in the past is the androgen deficiency in aging males the Adam questionnaire and this is a good way to assess symptoms of low testosterone because when do I treat someone with low testosterone I treat them if they have a low testosterone and they have symptoms of low testosterone and those may not be one in the same somebody can have a borderline level of testosterone and have none of these symptoms and I'm probably not going to treat them and then I have somebody that's got a maybe a low normal level of testosterone who has a lot of these symptoms and I am going to treat them and I think this is very reasonable and this becomes very important from my standpoint in evaluating patients but also from a practical standpoint when the insurance company says to me we're not going to pay for that that person's testosterone because they're in the normal range and their their testosterone testosterone is three hundred and fifty one not three hundred and forty-nine I'm gonna talk to them about this study and the this questionnaire and show them that the patient's symptomatic and they're gonna have to pay for the treatment so it becomes somewhat of a practical thing at certain times so what are the types and causes of low testosterone primary low testosterone or primary hypogonadism is due to testicular failure and there's a variety of different things that can cause testicular failure things that we know about like having had the mumps as a child certain types of surgical procedures certain types of medications in chemotherapy and there's a lot of testicular failure that we don't know about maybe some environmental exposure or injuries or certain types of activities secondary hypogonadism or secondary low testosterone is due to either hypothalamic or pituitary problems so that's in our brain the hypothalamus secretes a substance that goes to the pituitary which secretes secretes a substance which tells our testicles to to make testosterone most low testosterone is combined meaning there's a primary and a secondary issue but I can do some very simple blood tests to figure out which is which there are also some congenital issues common syndrome and certain types of acquired issues where there's tumors in the pituitary gland or something along those lines those are a little bit more specialized I will sometimes get specialized MRIs of the of the pituitary gland called the sella turcica to figure out whether somebody has a pituitary tumor I have a handful of patients that have pituitary tumors that secrete prolactin and create low testosterones and those don't need to be treated with testosterone they need to be treated with a different medication that treats the pituitary tumor so it's it can be somewhat of a complicated process but understanding it start to finish allows me to that evaluate patients more correctly so what does testosterone do male sexual function obviously erections desire libido the quality of sexual interaction all is affected by testosterone anabolic effects anabolic simply means building you up strengthening muscles strengthening bones hematologic effects this is the quality of your blood this is something that sort of relates to what why do cyclists abuse testosterone because it increases their their oxygen carrying capacity in the bloodstream bone metallic metabolism which we've already touched on mood and cognitive effects these are reported so mood and good mood bad mood and things like that it's fairly simple cognitive cognitive effects are important though we're seeing an aging population where there are patients who are still very very functional but may have the the start of Alzheimer's and dementia which can be debilitating and significantly problematic we can see some significant benefits in early Alzheimer's and and and dementia in when those patients have recognized low testosterone and supplement them and we can improve issues with their cognition and their ability to function on a daily basis and if we can keep people independent at an older age that's an important benefit insulin and cardiovascular effects this is where some of the controversy is but there are numerous studies that support the benefits of testosterone and dealing with and the development of diabetes and cardiovascular diseases now I'll touch on those as well let's talk about sexual function function for a second testosterone enhances enhances sexual feelings and sexual activity spontaneous erections it gives us our libido or desire so when somebody comes in and talks to me about their erectile dysfunction one of the first questions I ask them is do you have desire because that's a good barometer of their testosterone level we know that testosterone is more important in spontaneous versus any stimulus induced erection so again one of the questions I ask patients in deciding whether to evaluate them for low testosterone is do you wake up in the morning with an erection we know that testosterone plus these medications which were all familiar with that's viagra levitra cialis Taksin and stand rrah we know that that may be beneficial there are patients that don't respond that did and don't now respond to these medications who we supplement and then they consequently respond to those medications and we know the testosterone gives a quote-unquote better erection it improves blood flow it improves cavernosa smooth muscle that's the the vascular and smooth muscle within the erectile bodies in the penis and we know that it participates in vino occlusion so one of the one of the causes of erectile dysfunction that I seek commonly is venous leak erectile dysfunction blood flows into the penis but it doesn't stay there flows right back out and that can be due to a lower testosterone level and supplementing testosterone can it can cause those blood vessels to close and and allow the the engorgement of the penis to occur let's look at the anabolic effects the things that build what builds us up testosterone increases lean body mass lean body mass is important lean muscle mass is important and we're talking about muscle and bone mass we know that testosterone decreases all types of fat but specifically truncal fat the stuff that's right here this is where men get fat men men get fat here in the belly women get in the buck the buttocks and the hips and the and the thighs that truncal obesity is one of those things that we'll see and I'll notice men with truncal obesity who consequently have low testosterone we know that testosterone affects mesenchymal stem cell differentiation so basically what that means the mesenchymal stem cells are the the sort of the embryologic cell the cell that creates all the other cells in our body so we know that if it's--if testosterone has a positive effect here it's at the beginning of our are cell formation and that that can be very important that's an area that stimulated a lot of research as well so it's something that we're gonna see in the future human logic effects that's that's your blood your bloodstream we know that testosterone can improve hemoglobin hematocrit red cell mass this is again the Tour de France thing and this is where people abuse testosterone it ups their oxygen carrying capacity and they can be more competitive and we know a lot of cyclists have have abused testosterone the hematologic effects are more profound in the elderly we know that so what i'll see in older guys who I supplement testosterone their their blood counts go up they have more energy in many cases with that and we know that this effect what's called erythrocytosis or increasing that that oxygen carrying capacity it occurs more profound with injections of testosterone than patches or topical preparations things like that and this can actually be problematic I have some patients on testosterone replacement and I who are getting injections on a regular basis and I have to stop it because their blood count is going to I the blood count goes too high they are at risk of stroke so I have to be very careful in following in those men and sometimes we'll do different types of therapy in those men so the question is how does testosterone affect insulin I'll get to that but what we know is that there have been numerous studies that show men with lower levels of testosterone have higher requirements diabetic men have higher requirements in testosterone or an insulin replacement there are numerous studies that show that so what we think is that testosterone has some effect on the pancreas and we're not sure why it may be related to that mesenchymal stem cell effect that allows the pancreas to be more effective in producing cells islet cells that make insulin but it can be complicated but it's a good it's a good question what about bone metabolism there are multiple pathways but the bottom line is that testosterone supplement supplement ation can positively backbone metabolism and make our bones stronger we know that there are studies that show that lower testosterone levels increase the risk of hip fracture the question is does testosterone replacement decrease the risk of subsequently getting a hip fracture no studies have shown that which is interesting and and we're looking for studies to confirm this it's probably studies that are soon to be done and soon to come out the bottom line is bone strength is certainly augmented in patients who have normal testosterone levels or who are on testosterone replacement let's look at mood and cognitive effects again again I talked about dementia and Alzheimer's we know that mood is improved on testosterone replacement the effects on depression though are a little bit unclear there's some resistance to treating depression and when men are borderline or have normal levels of testosterone but have significant depression is it reasonable to supplement them and those studies have shown that we know again with cognition especially as it relates to early onset Alzheimer's and dementia that there's a benefit in testosterone replacement therapy so insulin and cardiovascular effects testosterone has a vaso dilatory effect meaning meaning that it opens up the blood vessels so you open up the blood vessels you get better blood flow to the things that need blood like your brain in your heart and your liver and your muscles and your bones and parts of us that maintain our intimacy we know there there's an inverse correlation between testosterone and cardiovascular risk so the lower your testosterone the higher your cardiovascular risk meaning the higher the risk of heart attack and stroke and it's not the opposite there is an inverse relationship between testosterone and that visceral fat so the lower the testosterone the more visceral fat and visceral fat may have consequences regarding we distance to insulin and requiring more insulin therapy bottom line right now we know large populations based studies need to be done those are ongoing as we speak what about chronic disease states chronic disease states probably this is number one cardiovascular disease but also malignancy hiv/aids obesity in the metabolic syndrome we know that in these disease states these chronic disease states low testosterone levels are common and understanding that and being able to evaluate patients with cardiovascular disease with obesity in the metabolic syndrome malignancy is a common thing I see it all the time patients come in who have certain types of malignancies and low testosterone and have a much better response to their treatments for their malignancies if their testosterone is is supplemented let's look at the chronic disease states a little bit more why it is testosterone low in these chronic disease states centrally mediated effect meaning that it's up in the brain and we know that with stress and malnutrition with pain medication usage with infections which are all common in chronic disease states that there's a centrally mediated effect that can lower the secretion of certain substances in the brain that leads to lower testosterone levels we know there's a direct effect on testicular tissue meaning that the testicular tissue is damaged and testosterones not true not produced like it should be produced and all of those have a deleterious effect in these chronic disease states we know that in malignancy 50% of men being treated at low testosterone levels there's three or four good studies showing this and we also know that with chronic opioid use that's pain medication so narcotic use in patients with with chronic disease State specifically malignancies we know there's a decrease in testosterone right now my focus is seeing patients who have these chronic disease states especially these malignancies they need to be evaluated evaluated correctly treated if their testosterone levels are low yeah it's a good question the question is are there medications out there that can lower the testosterone level there's really one class of medications that's that we know definitively does that and those are narcotic medications so what narcotic medications do is they go to the brain and they tell the brain to not secrete a substance called Kanata tropen releasing hormone GnRH so GnRH is this substance that is secreted by the hypothalamus which is this little gland inside her brain right in the center of our brain and that goes to our pituitary and tells our pituitary to secrete luteinizing hormone which then goes to the testicles and says secrete testosterone so if I take if I block your gonadotropin-releasing hormone your testosterone will go down one of the classic treatments for prostate cancer that is spread to the bone is to give patients a medication that will stop theirs hypothalamus from secreting genetic trope and releasing hormone so opiate medications are the common medications that can do that there's very few other medications that will interfere with testosterone production directly now you can look at certain types of chemo therapeutic agents that will have a direct effect on testicular tissue and prevent them from making testosterone but those are fairly infrequent and and it's not very common the the oral pain medications are probably the most common it was a good question you know you know they're there yeah the question is what about anxiety medications and their effect on testosterone and I will tell you this that's an area that that I'm gonna say I don't I don't know and none of us know I will tell you that flat out that there is a anti-anxiety medications and there's a variety of different types of those medications and you can look at antidepressant medications and the newer forms of antidepressant medications versus the older ones the newer anti-anxiety agents versus the older ones they all have a centrally that they're all active in the central nervous system to some extent and they can interfere with certain substances and this full nervous system that can have a negative impact on testosterone production it's just that it's going to be different in different people and we just don't know the answer to that right now directly yeah yeah the question is what about THC so tetrahydrocannabinol is basically marijuana and that's an area that in some patients depending on their other medical issues there can be some deleterious effects on testosterone production as the result of using THC now the other question is going to be what form of THC you know there's an edible form there's liquid form there's an injectable form and there are an inhaled form and all of those can can react differently as far as that their impact on testosterone not enough studies have been done to show it and and because of the changes in in society and how we're dealing with THC is something that we're gonna focus on sometime in the future that's a good question so let's look at the metabolic syndrome for a second what is the metabolic syndrome it's common these days I see a lot of patients with it and it's also known as syndrome X so the metabolic syndrome is obesity elevated triglycerides and glucose lower high-density lipoprotein that's the good cholesterol high blood pressure and low testosterone and I see patients with this all the time it's common and these patients need patients with metabolic syndrome are rarely evaluated for testosterone almost all of them have low testosterone and almost all of them can benefit from testosterone replacement therapy the Massachusetts male aging study is a big study done back in Boston we know that there was an increased risk of the metabolic syndrome in men with lower testosterone levels Finland had a great study a great population-based study men with lower testosterone level were increased risk of both metabolic syndrome and diabetes and what they also found was that testosterone replacement in those men helped correct these these maladies so multiple studies benefit our document the benefit of replacement therapy in both the metabolic syndrome and we know that it's protective or preventive when it comes to metabolic syndrome and cardiovascular disease what about prostate cancer 220,000 men are gonna get diagnosed with prostate cancer this year it's a lot of people it's the number one solid tumor that kills men in the United States right now and what we know despite what we've heard this by doctor colleague Carson is a urologist back at Duke there's currently no evidence that testosterone replacement therapy initiates prostate cancer or stimulates subclinical malignancy to become clinically evident basically what that means is that if you have prostate cancer we don't know it and we give you testosterone it's not going to make you worse I have a number of patients with prostate cancer who are not being treated for that disease because not everybody needs to be treated if they have prostate cancer who are on testosterone replacement therapy and are doing fine their PSA blood tests have remained the same their follow-up biopsies have not progressed testosterone replacement therapy in prostate cancer is fine treated or untreated and we know that definitively there are numerous studies that show that testosterone replacement therapy might increase prostate volume meaning it might make the prostate grow a little bit but there's a lot of things that make the prostate grow that mediate prostate growth testosterone is just one of them we know that PSA levels so that's the blood test prostate specific antigen are decreased in men with lower testosterone and when their testosterone is replaced their - their their PSA goes back up but that does not have that is not consequential to the development of prostate cancer so what we know is that the prostate is stimulated only to a certain level by testosterone and it's a relatively low level wiith it's less than a hundred so the number of patients that I see with low testosterone the percentage that have a testosterone less than 100 is is less than 5% most patients are above that so their prostate is maximally stimulated the majority of patients prostates are maximally stimulated even if they have low testosterone and supplemental testosterone 'men to stimulate their prostate more and that's that's a really important concept I still have colleagues that don't want to give testosterone replacement therapy and men because of a risk of prostate cancer and that's erroneous that's wrong and it there there the patients are are losing the benefit of testosterone replacement therapy in that setting so there was a study that was done ten patients had their prostates removed for prostate cancer they were found to have low testosterone and they were treated none of them had an increased PSA but they all had significant improvements in their quality of life you know from my standpoint I always follow prostates and PSAs and patient men who are on prostate who are on testosterone replacement therapy and more because of a medical legal issue these seem very few problems in patients on testosterone replacement therapy as it pertains a testosterone replacement therapy as it pertains to the prostate it's it's really a myth and and unfortunately we have to focus on this because there's still a lot of physicians that don't understand this so bottom line most studies suggest no association between testosterone and the incidence of prostate cancer that is really the bottom line so let's look at testosterone replacement in the Adri male if the aging male is a common entity in my practice I see more and more patients in their 70s and their 80s and their 90s that want to live their lives they want to be active physically they want to be active mentally they want to be to maintain their intimacy they don't want to sit in the corner and curl up they want to live their lives and it's it's a good thing from my standpoint this segment of the population is increasing 15 thousand people turn 65 every day in the United States it's a huge segment of our population and it's the majority of my patients are in their 60s and 70s and 80s and 90s and I see guys in their 80s that come in and and have questions about sexual dysfunction and and and testosterone and it's a good thing five million men at least probably closer to eight to ten million have low testosterone 5% and this is a little bit of an older number it's probably more right now five percent are really receiving replacement therapy at this point in time what percentage can benefit from testosterone replacement therapy is who knows but because of a variety of things they aren't being evaluated and aren't being treated we know that testosterone secretion decreases with age the short-term consequences diminished libido maybe some mood related issues I shouldn't probably put depression here but mood related issues longer-term consequences bone loss loss of muscle mass cardiovascular risks diabetic issues obesity a cognitive dysfunction so again this baby boomer population is growing and they have a strong desire to remain active and they should so again the prevalence of hypogonadism low testosterone underestimated and it's certainly an unrecognized and unappreciated condition you know I I somewhat harp on my primary care colleagues but they have a lot on their plates they see patients with their high blood pressure and their cholesterol and their diabetes and a lot of different things it's hard for them to to include testosterone and and and hypogonadism in the evaluation so I say send them to me I can see them and and and deal with it and and I'm more than happy to do that we know that testosterone levels begin to decrease that between the age of 30 and 40 and we know that they decrease relatively significantly so that at the age of eighty at least fifty percent of men have low testosterone and a lot of those men are going to benefit from testosterone replacement therapy so why is it that only five percent of men in the agent population they who are a hypo cuñado who have low testosterone so why is it that only five percent really received therapy evaluation in therapy it's your fault it's my fault I hate going to the doctor a lot of men are that way I think that's changing but it's still you got to come in you sit and you wait and I'm late and a 15-minute visit turns into two hours no nobody likes that yeah I think what you're asking is what about the specifics of replacement therapy that's your question I'm gonna get that out in two seconds all right those symptoms are a normal part of Aging that's sort of me I'm saying that to you and I don't do that but me being physicians and all we say that when people come in and they're a little bit overweight and they're tired and they've lost their energy level on they're losing their their desire for intimacy and well that's just a normal part of Aging you're you're 80 years old you're 70 years old who cares we should care because that's why you're here we want to improve your quality of life that's our goal we know that testosterones in Creek lit incorrectly assessed or not assessed at all and then perceived risks of testosterone replacement therapy prostate problems cholesterol problems cardiovascular problems but what I've said and what I'm going to say again is that those are myths and those are myths and I'll say that every day the treatment approach in the aging male we want to improve libido mood feelings of well-being energy level muscle mass pressure preservation of bone mass and we know subsequently that testosterone replacement therapy can protect the heart and Men as they age and who are receiving testosterone replacement therapy contraindications when is it that you're going to come and see me and I'm gonna say you can't have testosterone pretty rare to be honest with you it's low I'm going to treat you probably prostate or breast cancer and breast cancer can occur in men those that aren't actively treated for prostate cancer I may have some reservations about treating but again it's it's it's very much individualized prostate growth and urinary issues are probably not exacerbated significantly with testosterone replacement therapy we used to think that if you had sleep apnea and I treat you with testosterone your sleep apnea got worse there's two good studies out in the last year that show that that's not the case men with congestive heart failure may be at some risk especially as it relates to the to the blood count and increase in the blood count but all of those are relatively there there's very few men I look at who have low testosterone and say you can't be treated it's it's a pretty rare rare occasion that that occurs let's get over this one so we know specifically when we talk about testosterone and libido or desire one of the questions is is libido our sexual desire correlated with overall well-being a couple of studies have shown that that if we have a strong libido our sense that our lives are good even if we're not sexually active is much better we know that libido parallels testosterone secretion and those studies have been confirmatory and and don't need to be repeated how about erectile function and this is an area 25 years ago we used to anybody that got that had erectile dysfunction we treated with testosterone replacement correctly or incorrectly so that wasn't really right and we know that eunuchs those that lose their testicles before puberty still were able to get erections we know that testosterone facilitates cavernosa smooth muscle cavernosa smooth muscle is that the structure of our penis that allows us to get an erection and we know that men with lower testosterone levels especially men who have lost their prostates and no longer have DHA to dihydrotestosterone have a significant loss in the quality of their cavernosa smooth muscle their penis shrinks that's the bottom line we know that testosterone supplementation and can be vaso dilatory and can can improve the structure and the function of the penis after after prostate removal in certain cases and again I talked about this Salvage therapy so what I have is I have men that come in who have been treated with Viagra and they'll tell me that I used to use viagra worked great and now it doesn't work anymore and there's a percentage of those men who have underlying low testosterone who are then supplemented with testosterone who will find that viagra will now work for them so there's a an interaction between the pde5 inhibitors that's viagra levitra cialis those medications and testosterone and we know that that combination therapy can sometimes be very effective in salvaging men who no longer are able to get an erection so let's look at testosterone replacement options how do we give testosterone to you we give you injections there are patches that you can wear there are gels that you can put on your skin there's a little thing that you can put right in your cheek and it it absorbs through the cheek there are oral preparations and there are pellets that go under the skin all of those are options to a certain extent this one is not in the United States there are no oral preparations in the United States the oral is rapidly metabolized it's risky and it's rarely prescribed even overseas I had a patient recently from India who had been on oral testosterone therapy he has a higher risk of liver cancer that's a big deal that will kill you so there there's no oral preparations in the United States the intramuscular injection you come into my office once every two weeks and we get a shooting you get a shot in the butt so what happens is you get the blast effect the testosterone level shoots up and it trickles down over two weeks and that is not what happens in our bodies but because of insurance issues and convenience and other things like that this is probably the most common way that testosterone is given this is the brand-new form of testosterone the injectable in the United States that's been around europe in canada for a long long time it's been very effective this is an every ten week shot so you get this shot of testosterone and it sits in your muscle and it slowly gets it gets through your system over a 10-week period of time and I can tell you that men who've been on the every two week injection who we convert over the every 10 week will tell me they don't feel as good almost every one of them and they just they you you get that big burst and it makes you feel good the transdermal approach whether it's a patch or a gel is the most physiologic because you put it on every day and you get some testosterone every day and you get a better steady-state of testosterone the problem is you probably gonna pay $400 out-of-pocket monthly for this and majority of us can't afford that the subcutaneous this is a little I make small little incision over the your back pocket and your in your buttock and I put some pellets and the pellets slowly leach out over three months to 12 months the majority of patients about six to nine months so those are the options as far as monitoring i I do some tests and I see patients on a regular basis afterwards so to make sure that things are okay so again the oral preparations we're we're gonna just ignore these there are no oral preparations you can't take a pill and correct your testosterone there is one exception there there's a medication called clomid so what clomid does is it stimulates our hypothalamus which then indirectly stimulates our pituitary and makes our tests our testicles make testosterone none of the insurance companies will pay for clomid I can sometimes use it in patients who are infertile but it's it's tremendously expensive I use it in a few younger patients but it's it's not something that really can ever be used so the oral preparations are not available in the United States it's still worldwide a lot of people use it this is again the injection options I use testosterone sippy Nate that's the one that most people use in the United States if you lived in London you'd get this one and that's just the way it is there's no testosterone sippy Nate in London and there's no testosterone and an Tate here in the United States and they're almost the exact same I'll tell you that they are slightly different when in their chemical composition and they're there when they're manufactured they are in an oil and the oil in Ananthan is different than the oil in sippy Nate the bottom line is they're very similar this is the longer acting one that has been around for a long long time but just FDA approved so the testosterone sippy Nate is relatively inexpensive it's effective you get the burst and you trickle down over two weeks most patients are on a once every two week and that's the standard recommendation once a month doesn't work you're gonna you're gonna be low for a long period of time or you're gonna get such a high dose to begin with that you'll have other negative side effects all of the injectable ones the sippy Nate are gonna cause some potential to increase your blood count like I talked before people note that their symptoms somewhat fluctuate and technically speaking you got to come into my office and get an injection and that's a nuisance I know it but despite those those downsides this one is the most popular the patches there used to be a scrotal patch that nobody ever uses you know can you imagine sticking a patch in your scrotum every day and taking it off and I don't think I have to say much more than that but it it was provided significantly helpful symptomatic relief the and return patches these are non scrotal they go on your stomach and they leave a welt and I can if you took your shirt off I and you'd have eight welds on your body and they itch just made no sense people don't use them much anymore at all some people like them but most people don't the gels are the ones that again I think we should use most often and they're the ones that make the most sense the problem is they're expensive and the drug companies know it and they're making a lot of dollars on these medications most of the insurance companies really balk when it comes to these and you got to have a lot of reasons to convert someone from the injectable to the to these so there's an or gel there's Testim there's acts Iran for testa and there's compounded formulations which probably aren't as effective but are much cheaper so there are compounding pharmacies there's one in in Flint called diplomat it's actually there's one in Grand Rapids there's one up in Wisconsin called woman's health but it's for men as well I don't know why they call it women's health but there are compounding pharmacies that make their own testosterone it's much cheaper but it seems to be less effective in some regard relatively convenient but you got to put it on every day really no skin irritation for the most most part the gels can be transferred to others so if I'm putting energy gel on my chest and then hugging my wife she's gonna all notice it's a deep deep voice and a little bit of a beard and I'm not sure I'd like that but so you have to be careful with that there can be drug accumulation where the levels get very high there are differences in how effective they are in in some patients and there are some patients where you know when you think of the skin the skins a barrier so when I'm putting something on my skin it's not being absorbed that's how our skin works but these substances have compounds in them that allow the testosterone to get through the skin some people it doesn't doesn't work very well though their testosterone levels don't go up at all and they're telling me I'm they're using a lot of this Joe on a daily basis and their testosterones are still love some people don't respond to them the buckle discs that's the thing you put in your mouth is I think I'd probably use this 20 times and everybody complained about it their gums irritated it was difficult to eat and drink and it was relatively effective but it's just not practical the test about pellets again 10 to 20 pellets under the skin in the bottom you'd say about a three or four minute procedure or a little tiny incision and most patients they will have a great testosterone level for six to nine months the problem with this is that the insurance companies again want to balk at this I have probably 25 or 30 patients on this most of them do great with it and love it some pay for it and some of their insurance companies pay for so to wrap things up here I appreciate everybody's patience we know that number one testosterone is the primary male antigen that's the male hormone we know that low testosterone is a common common problem short and long-term effects of low testosterone can be significant whether you're talking about your libido and your sexual dysfunction or you're talking about effects on your muscle mass or your mood and your heart and your bones and your brain and things like that we know that the assessment is straightforward but it's got to be done correctly treatments are varied and relatively straightforward whether it's an injection or a topical or a pellet there's their options treatments have really acceptable and and what I would say fairly minimal risks so it's a it's a process that I think deserves a pretty ample discussion when you're talking to your physician but it's got to be evaluated correctly and and all the treatment options have to be discussed with you so it's not something that you can just take a two minute discussion and head to the next patient something that needs a little bit more attention I'm willing to answer questions I can stay up here as long as everybody wants yeah the question is how is the assessment done blood test it's a warning again you got to have a blood test fasting for midnight the night before first thing in the morning simple you can get a blood test it's very easy to get done and the way that we like to do this we've again what we do is we follow the endocrine society guidelines so the specific guidelines are that if you have your first blood test and it comes back less than 300 that's low and by definition and by following the guidelines we repeat it and we also get a luteinizing hormone so that that tells me whether you have primary or secondary if it's the testicle or the your hypothalamus or pituitary and that gives me some indication of why it's low so two consecutive testosterone is less than 300 that's low and deserves treatment yeah it's good question yeah the question is what about our diet and what about supplements you know the problem with supplements is that there are so many of them and they're not well studied because because the FDA says based on a supplement you don't need these studies other than to look at their safety factor but do they have a positive impact on testosterone they could and if you go into G and C or any health food stores they're gonna have a variety of things that they're gonna tell you are going to increase your testosterone whether that happens in you or not remains to be seen you know from a diet standpoint I'll be I'll be sort of broad in general I will tell you that a low-fat low-salt diet especially avoidance of high sugar in your in your diet and processed foods and that's hard you know if you walk through a supermarket and I picked up some salad dressing and the number one ingredient in the salad dressing was high fructose corn syrup that's a simple sugar that's gonna have some negative effects on my pancreas and and and if you're constantly eating those medications that can be a big problem diet is a huge issue it's one that we as physicians have ignored for a long long time but it's incredibly important yeah yeah yeah the questions about about treating that it's if you have low testosterone I can't correct it in in an assent I give you the the medication it's something where you're gonna have to keep seeing me over a long period of time I'm not sure if that's what you were getting at yeah that's it's it's more or less there's not a permanent fix and you know that's a good question re once you embark on treatment do you have to be treated for the rest of your life that's up to you really if you're seeing the benefits of treatment should you continue to be treated and the answer is probably yes but at what point in time do you say I'm done I don't know the answer to that the question is most of the patients that I treat been we've been with me for a long time yes and no I have a lot of how I get a lot of new patients the way my our practice is set up is there's four of us we do the things we want to do so we aren't Jack's of all trades there are the things that I like to do and dr. trade where dr. Willoughby and dr. Bates do the things that they like to do and it's better for the patient because I'm doing I'm seeing and evaluating doing the things that interest me I'm less interested in female the female aspects of urology whereas dr. Bates does that so most of the patients that I see for testosterone replacement therapy have been with me for are gonna be with me for a long time so that that's sort of the the quick answer to that the long answer yeah the question is how does testosterone impact sickle-cell it doesn't it's not gonna make it any worse or better and there have been studies that have looked at that so if you've got sickle trait or if you have sickle disease it doesn't change things at all that's a great question yeah since this is a steroid are you gonna are you gonna get in a bad mood or do bad things on testosterone a little cholesterol the steroid so if you eat a high cholesterol meal that doesn't make you angry I guess for the most part if your testosterone levels mm yeah that will make you angry no two ways about it but out of the normal dose if you come in and are getting 200 milligrams every two weeks your peak levels gonna be about 400 to 500 that's a normal level a high the high range of normal is about 800 I've had patients that have come in and have testosterone levels of 2,000 not because I'm giving it to them it's usually patients that are abusing it one way or another they're either getting it on the street or I do have patients that can give themselves their own testosterone there their significant others a nurse or something along those lines and they have a tendency to abuse things now and again I have a number of patients that have I've seen that one no they're the that's sort of a myth about the patent stuff you know if you look at something like viagra so what's going to happen when when viagra loses its patent the pharmaceutical that picks it up and starts to produce it and make it they're not gonna lower the price they're gonna keep the price the same it's the same with testosterone as soon as that happens they're gonna continue to charge that price they can charge the price they want the competition will it plays less of a role because they're because the way the patents work and in in the pharmaceuticals so the corollary to that is the compounded stuff if you can get the compounded stuff at a significantly lower price what you can the question is will you respond to it and it has to do with how it's made and how it gets through your skin so I can I can prescribe compounded testosterone to you through diplomat pharmacy and they can send it to you in the mail you could put it on every day what's but there's a significant portion of patients that don't respond very well to the comp that forms just less effective so but they answer it's gonna it's gonna come off patent to some extent but the price is probably not gonna go down it can tell that your PSA so so the question is if I give you testosterone as your PSA gonna go up in might but what why is that a problem the more important question is like we said testosterone replacement therapy has no impact on the development of prostate cancer and that's what PSA is for yes so I I would tell you I follow it but I don't worry about it and I encourage patients not to worry about it alright it's a good question yeah I the question is does this sub supplement cause kidney problems or is it going to help your testosterone the only way you would know is to measure your testosterone level before and after and to be honest with you that is a substance that there are hundreds of those I'm not familiar with that we could do that that's easy before and after yeah yeah and the question is you've got a blood test for testosterone then you're told it's normal what does that mean and that's a really good question and on to a good question because if you get your blood tested and it and you're told it's normal Mike my question to you is this was your testosterone greater than 350 because if you look at the normals on the on the the result the normals are going to be from 220 up to 850 so really that doesn't mean a whole lot The Endocrine Society guidelines The Endocrine Society in the United States is a group of enter chronologist in this country who are dedicated to enter current issues in patience there they're smart people numerous studies have been done if your testosterone is less than 300 that is abnormal and I see patients all the time that we're told their testosterone was normal and it is if you look at the assay based on what the assay numbers are that's different than what the enter current society says is normal and abnormal in us so it behooves us as patients to know what that number is that's key yeah yeah the question is is this part of a typical blood test the answer is probably no they really have to do this specifically you know a lot of blood tests that we as physicians order our panels the order a chem 12 or a chem 17 is testosterone part of any normal panel no you have to specifically order a testosterone level and your insurance company isn't going to pay for it unless it's it's linked to a specific diagnosis or you're gonna have to pay for it that's why when you go in and get your blood test sometimes they'll make you sign a form that says if if the insurance company won't pay for it you're gonna pay for it that's all this coding nonsense that we have to deal with so unless you your physician has specifically requested a total testosterone you're not going to get one the question is not sure how to phrase that actually the big issue your physician has to code things correctly or you're gonna be responsible for things it's it's a nuisance so yeah I think I think your question is who really in the physicians who's really the one that understands this and should evaluate it treat it you know I'm not gonna stand up here and tell you that if you don't come to me you're gonna make a mistake I think there's a lot of the primary care physicians that do a really really good job with this they have a lot more on their plate than I do you know when you come in to see me I can I can pretty much figure out what's going on in about the first 30 seconds and really have a game plan in my mind the primary care physicians have a whole host of things to deal with so I'm not gonna look at you and say you need to go to a urologic specialist to get yourself evaluated I would talk to your primary care physician about it and the the primary care guys that I know here in Holland and that I deal with on a daily basis that are pretty comprehensive and pretty good guys and if they're uncomfortable or if you need it for your peace of mind and you want that evaluation through one of us absolutely you know you don't need a referral and all that stuff is is done you can you can call us and make your own make an appointment yeah yeah your statements good it's a it's it's has to do with referrals priority is the one priority health is the one insurance company that really digs their heels in when it comes to this and and the thing is if you're in the Medicare age doesn't make any difference you can come to me you don't need to referral so you have a question the question is faster muscle recovery with no not with testosterone not if you're in the normal range no you won't get faster muscle recovery from exercise you're talking about no you won't if you're if your testosterone is in the normal range you won't get faster muscle recovery that if you're no they use it the cyclists use it because of its oxygen carrying capacity that's why they using other questions yeah yeah you should be treated the question is specifically history of prostate cancer treated and testosterone replacement your PSA is undetectable I would have zero problem treating you zero and if you talk to the person that knows the most about testosterone replacement therapy in the world Abe Morgan teller in at Harvard he's incredibly bright has done a number of studies he will look at you and flat-out tell you that you should be treated and I hate to contradict what another physician has told you I'm gonna be honest with you I have no would have if you were my brother I like my brother he's a he's a good guy I would tell you flat out you need treatment yeah yeah the question is how does cardiology fare in all this again you know I think that they have a little bit of a focus on what they do but I talked to the cardiologist all the time about testosterone replacement therapy and I've got good friends at West Michigan heart that have been there for a long long time and our proponents of testosterone replacement therapy in overall prevention and health and they're very much a proponent of it III would tell you that I think they're a good studies to show that your vascular health and your cardiovascular health in our augmented and significantly improved in men who are treated men with low testosterone who are treated yeah there's all sorts of studies that show yes and no the question is if you ejaculate regularly are you now the healthier prostate there was a study that came out about two months ago that said if you if you ejaculate regularly you're not going to get prostate cancer so I left that on the counter for my wife it's been an hour and a half I know I appreciate everybody coming and listening and testosterone is a great subject it it has some significant upsides there's lots of controversy it's it's a topic that we need to talk about I appreciate everybody coming and asking questions there's a good group of people and if you have further questions call my office and ask to speak to me I'm more than happy to talk to you over the phone all right thank you everybody have a nice evening good weekend good holidays next week