Dr. Stephen Petteruti lays out the plain facts about testosterone therapy. When it’s appropriate, how it works, what it does, and what it doesn’t do.
The promise is nothing short of a better life. Confident, fit, handsome men are depicted in the commercials along with their satisfied and equally fit female partners. Message; if you don’t see yourself in the figures on your TV, you’re missing something. That something has little to do with you, and much to do with your hormones.
This article will review the validity of the promise both for men and women when it comes to the potential benefit of testosterone therapy.
For the purpose of this article, we will presume that the reader has already maximized the nonpharmacologic interventions to support healthy testosterone level. Namely, appropriate amount of exercise, healthy diet with avoidance of large amounts of soy (soy is full of phyto-estrogens which can interfere with testosterone function), healthy sleep cycle, appropriate stress management, and maintaining your ideal body weight.
The phenomenon of low testosterone and the potential to treat it seems to have recently burst onto the scene. A combination of new topical creams that offer affordable and safe delivery methods, along with an aging population and a better understanding of the benefits have all led to a change in attitude regarding testosterone replacement.
While the marketing from the big pharmaceutical companies has clearly elevated awareness and stimulated demand, there is sound science and substance behind the marketing hype.
Imagine if you went to your doctor with symptoms of constipation, weight gain, hair thinning, cold intolerance. After some blood work, your doctor would diagnose you with hypothyroid (low thyroid function) and would offer you treatment which you would gladly and without hesitation endorse.
Imagine you went to your doctor with symptoms of excessive thirst, frequent urination, blurred vision, and fatigue. After some blood work she would diagnose you with diabetes. You would likely accept treatment for this form of glandular failure with resolution of your symptoms.
So why should there be any controversy when you present to a physician with symptoms of decreased strength, diminished energy, diminished sexual interests, depressive symptoms, and with blood work diagnosing low testosterone why not treat that as well?
Many physicians, when faced with this clinical presentation and when it is supported with clearly abnormal testosterone levels, would either treat or refer for treatment.
Things become more complicated when we ask the question, “what is a normal testosterone level?”
Testosterone levels usually start to declined sometime after age 30, and continue a steady decline from that point forward. Many of us in the anti-aging field have embraced the concept of “hormonal optimization” in this philosophy of treatment, and overtly abnormal lab study is not the only criteria to support treatment. A patient presenting with appropriate symptoms and with suboptimal testosterone levels is a candidate for active therapy. Even if the labs are technically within the normal range, the real question becomes what is the optimal range for that individual? What hormone level is best suited to maximize health, lifespan and well-being?
Hypogonadism, or low “T” syndrome as it is commonly known, is more of a clinical than a laboratory diagnosis.
Common symptoms of low testosterone include; fatigue, irritability, depressed mood, diminished strength, muscle and tendon soreness, diminished sex drive, decreasing quality of erections and short-term memory impairment. A patient who presents with this cluster of symptoms, and in whom other correctable causes have been ruled out, is
a candidate for hormonal optimization treatment regardless of the blood levels. While blood levels can tell us what your current level of testosterone is, it cannot tell us what the level was when you were in your prime.
Many of us in the antiaging field believe that hormone support is essential to slow the aging process. There is a growing recognition in the medical field that routine replacement of sex hormones as well as supporting other aspects of hormonal decline can prevent many of the symptoms associated with the aging process. Whether or not such a medical approach will ultimately extend lifespan remains an open question, however given the choice between traditional aging with its fade into infirmity, or advanced medical intervention to support a more youthful body and mind, it is reasonable to expect that treatments which preserve youthfulness are more likely to extend
As others have noted, our hormones don’t decline because we age, we age because our hormones decline.
So there you are, in middle age, having lost a little bit off your fastball wondering if this is as good as it gets. Hormone therapy offers you an alternative to the passive erosion of your youthful well-being. Here are some things to consider as you contemplate the choice between traditional aging and medical intervention to alter that course.
What are the potential adverse risk to using testosterone therapy? The million-dollar question is whether or not this treatment will cause an increase in prostate cancer. Thus far, there has been no strong evidence that replacement of testosterone to a more youthful level will increase prostate cancer. Dr. Morgentaler in his book, “Testosterone for Life” has completed an eloquent and very readable review of the evidence on this topic. All the evidence currently supports that there is no connection between testosterone treatment and increased prostate cancer risk. Still, we must recognize that the final word is not in on this issue. If you are in your late 40s, early 50s, or beyond, the truth is you don’t have the time to wait for the final answer. Those studies are decades away and may never be performed. You simply have to use the evidence at hand and combine it with your own philosophy and your physician’s guidance to make your best decision.
Some other less ominous risks include; increased acne, potential for some hair thinning, increased blood count, reduction in testicular size, reduced fertility.
Of these potential side effects, the reduction in testicular size is almost inevitable but barely noticeable. The increased in blood count does occur in some cases and may require you to either reduce your dose or donate blood in order to keep the blood from becoming too thick. Hair thinning is rarely seen beyond your genetic predisposition. Acne can occur, it is usually managed by alterations in therapy. If all this sounds like a bit of a nuisance, you’re right it is. Living well, living younger will require work on your part.
After weighing the pros and cons, you’re leaning towards considering treatment. What’s next? The proper approach to therapy will respect the delicate balance between all the hormones in your body. As the anti-aging expert Pam Smith has often said, “the hormones are a symphony”: they must all play in tune with you to be your healthiest.
The correct approach to treatment goes far beyond merely smearing testosterone cream on your body and hoping for the best. A well-trained physician will take the time to thoroughly assess all the variables affecting testosterone level and build a treatment plan that balances all the functions of your body.
Testosterone levels cannot be assessed in isolation. Before moving toward testosterone therapy, the adrenal glands, the thyroid gland, nutritional health and toxic levels must all be properly assessed and optimized. Often, symptoms will resolve in hormone levels will naturally escalate with proper holistic intervention. If, after balancing these elements, the hormone level still requires treatment there are three basic approaches that one can use:
- Injectable treatments. These typically consist of once- or twice-weekly injections that can be self-administered. In my practice I train patients to inject the outside of the thigh with a small needle that is very easily tolerated. The benefit of this approach is cost— the treatment typically is generic and inexpensive. The other benefit is rapid absorption. Some of the downsides can be a tendency for spikes and troughs with regard to blood levels.
- Topical creams or gels. This involves applying a cream or gel typically under the arm. The benefit is ease of application. The downside is the risk that the cream can rub off on a partner, causing their testosterone levels to rise. Many experts feel that the topical approach is better for improved erections. However, others are concerned that the topical approach is more likely to cause acne. When using topical creams, it can become difficult to monitor the result in blood testing. Saliva testing may be used to gain an accurate reflection of the amount of testosterone in the blood.
- Subcutaneous implantation of small pellets. These have the benefit of not requiring any maintenance activity on the part of the patient as they can last for months at a time. They have the disadvantage of requiring a minor office surgery, and lack the ability to adjust dosage after implantation.
For cost and ease of monitoring, as well as reliable effect, it is been my practice to favor the injectable form.
Doses are dependent upon the individual and the clinical response. It is helpful to know that the normal male produces between 7 and 10 mg of testosterone daily. Given this as a healthy baseline, it is uncommon to use weekly doses above 160 mg injectable.
In my practice, I’ve seen patients coming to me having previously been on doses as high as 2000 mg weekly. These patients typically have been self-dosing from hormones acquired at the gym or on the Internet. This type of super dosing will give a temporary, almost euphoric high as well as a powerfully muscle-stimulating benefit. Needless to say, it is fully unsustainable and not at all conducive to good health.
Once it is started, testosterone therapy will become a lifetime intervention. Over time the testicles will lose their ability to manufacture their own hormone, and you will be dependent on testosterone therapy to ensure optimal health. Again this is quite similar to patients that require ongoing thyroid hormone, insulin or other forms of hormonal support.
There is an alternative testosterone therapy. In some cases hCG can be used to stimulate the testicle to manufacture more of its own testosterone. This approach typically works on younger men and those who do not have long-term testosterone exposure. In some cases, hCG can be combined with testosterone therapy to preserve testicular size and enhance ejaculatory volume.
Well the final results are still not in, testosterone support not only improves strength, energy, libido function in sexual performance, but it also is a direct stimulator to bring function. Testosterone therapy can enhance circulation to the brain and accelerate the speed of electronic impulses traveling through the brain. Many of my patients tell me that they feel more alert and more mentally capable after starting hormone therapy.
There are some theoretical reasons to believe the proper hormonal support may diminish the risk of Alzheimer’s and other forms of dementia.
Testosterone is a hormone that is not only essential for proper male functioning, but it is also critical for women as well. Just like men, their testosterone levels diminish as they age. Symptoms such as decreased libido, osteoporosis, muscle weakness, diminished mental sharpness can afflict women as a consequence of hormonal depletion. When properly balanced with other sex hormones, testosterone support in women can have profound benefits.
Hopefully, you will live to a healthy old age. In that case you must face the question of whether or not you want to embrace hormone replacement or choose to let the opportunity pass. The era of passive aging is over. The exciting opportunity to actively manage aging presents with it the complexity of having to make decisions that previously had not been available.
Continue to study and reflect on this topic. Just bear in mind that timing matters. Many of the long-term benefits of hormonal support will be lost to you if you do not take action and start at the right age. This is especially true with regard to neurological preservation.
And remember, the hormones are a symphony. Be sure you pick the right conductor!