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Testosterone Treatment

Testosterone Treatment

Men these days aren’t what they used to be. And I mean that literally. The average testosterone level of American men has declined by roughly 1 percent per year since at least the mid-1980s, if not longer—that’s more than a 25 percent decline in 30 years. Nor is this strictly an American phenomenon; similar results have been reported in the UK and Denmark.  and Testosterone: Myths & Facts

Testosterone Treatment: Myths & Facts

The facts are, low testosterone affects 40% of men over age 40 and can affect your overall well-being? Symptoms of low Testosterone include diminished energy, motivation and sex drive, loss of muscle and increased body fat, along with erectile dysfunction. You really can do something about it. Watch this candid discussion about signs of low T and see how it can help with reatment options for effective, long-term results.

Video Transcript

I'm going to talk tonight about testosterone testosterone has been in the media quite a bit there's a lot of information and misinformation about testosterone and I think it's a timely topic I like these things to be kind of low-key so if you have questions during raise your hand and stop me and ask questions I think it's the best way for everybody to learn about things I learned just as much for your questions as everybody else in the audience so please please feel free to ask questions there'll be a session afterwards as well so in my practice there's four of us for a urologist at Holland Hospital and we all sort of divide things up but we all have our little areas that we're interested in men's health is one of my concentrations and a large part of my practice is testosterone and testosterone replacement tonight I'm going to talk about some of the things that are important about testosterone and I can tell you that men with low testosterone really need to think about testosterone replacement because the the side effects of low testosterone can be significant and there's a potentially potentially a big upside to testosterone replacement therapy testosterone replacements important men with low testosterone who are symptomatic from low testosterone I'm a big fan of replacement I think that I think testosterone replacement can be very important and I think what's important is not only the replacement but following patients who are on testosterone replacement that's very important and I think what's happening is that these somewhat fly-by-night testosterone replacement centers are popping up in strip malls the men's health clinic that type of thing and they're interested in getting you in there they're interested in more your wallet than your health so you've got to be really careful when you're when you're seeing somebody for testosterone replacement it's a sticky subject and I would I would caution people to be diligent about who they're seeing and who's who's treating them so what are the issues in men's health in 2016 that it's important certainly dietary and health maintenance and I think a big part of what I do when I talk to patients about testosterone and testosterone replacement as well as about erectile dysfunction and other parts of my urological practice is health maintenance and and dietary health that's really important cardiovascular disease is a big topic and we had a big cardio cardiovascular center here now that we've partnered with with Holland Hospital bone and joint health is obviously important prostate cancer is a huge issue twenty-eight thousand men are gonna die from prostate cancer this year and that's the same as it was 20 years ago so we need to do a better job of screening men and treating men benign prostatic disease that's just difficulties urinating erectile dysfunction is important erectile dysfunction is a marker of vascular disease you have erectile dysfunction you have a higher risk of heart attack and stroke we know that as a general statement testosterone here and then kind of the business of medicine outcomes versus fee-for-service you know traditionally we've been a fee-for-service health care system when you come to see me I do things to you and I get paid to do them I don't necessarily get paid to make you or keep you healthy and now outcomes are more important for me I get I get now reimbursed and incentivized based on outcomes and that's an important issue so what's the big deal with testosterone testosterone has direct and indirect effects on every organ system in the male body testosterone can can interact with all cells in the body hypogonadism that's low testosterone is a crucial factor in patient with chronic disease states so when I talk about chronic disease states I'm talking about diabetes congestive heart failure hypertension prostate cancer all of that those chronic disease states that are being managed testosterone plays a role in there's a shifting demographics and what I mean by that is that 15,000 people are turning 65 in this country every day so we're seeing this burgeoning population of men as they as they age and what I've seen in 22 years of practice is that men as they age don't sit in front of a TV and put their feet up they want to interact with people they want to be active they want to live their lives they want to do things they want to work they want to be intimate they want to maintain relationships and that's important aspect of things so we're seeing more and more patients that are over 65 and are maybe a higher degree or more susceptible to low testosterone we know that five million men are affected in the United States by low testosterone that that number is wrong it's much more than five million so now that we're talking about this disease process and talking about what the symptoms of low testosterone are that number is going to increase significantly there are huge potential benefits of treatment what are the risks of testosterone replacement that's an area that's garnered a lot of controversy there was a paper in the journal of the American Medical Association that came out that attracted a lot of interests and talked about increased risks of heart attack and stroke and men on testosterone replacement therapy but if you drill down into the statistics that just statistics actually would tell you that just the opposite thirty medical societies petitioned the journal the American Medical Association to retract that paper hasn't been done but again the risks are important is something that we need to talk about and discuss when we when I see patients with low testosterone and talk about treatment so four to five million people have low testosterone men were specifically what we're talking about and again this number is low but only 5% of effective men are currently being treated and that's not that's not a good thing tonight what I want to talk about is regulation and physiology of testosterone secretion what does testosterone come from that's an important thing to understand testosterone deficiency in chronic disease states and again diabetes high blood pressure congestive heart failure prostate cancer those diseases that are managed on a regular basis we're going to talk about testosterone and the metabolic syndrome testosterone replacement and prostate cancer testosterone replacement in the aging male sexual function and I'm going to touch on some replacement options as well so this is how we get testosterone and how it's made in our body it's made in a couple different places but ultimately cholesterol we're testosterone comes from and cholesterol gets converted to this and this and this and this and this and there we get testosterone this is a cascade of enzymes that does this and then with this enzyme we get the female hormone so all men have some female hormone all women have some male hormone and both of those levels are important for their health as well but that's the the science of things we know that testosterone is the primarily primary circulating androgen androgen means it's a steroid that builds us up it's supportive its keeps us healthy builds our muscles and builds up builds our bones and builds our brains and other parts of our body simply stated this is the the baseline secretor this comes from the hypothalamus this subject that this compound right here called can addict rope and releasing hormone that creates secretion of luteinizing hormone from the pituitary the lady cells are in the testicles and those are what stimulated to make testosterone so that's how it's made it's it's it's simple the adrenal cortex the adrenal gland is the little gland on top of the kidneys we all have the adrenal glands and no those are important you really can't live without your adrenal glands or you can live with difficulty without your adrenal glands 5% of our androgens come from the adrenal glands we know that the secretion of testosterone is pulsatile we get a kind of a burst in the morning and there's a little bit of a burst in the afternoon as well and that's again a supportive thing again highest concentrations in the morning and one thing we know about when we measure testosterone in the bloodstream all the testosterone that we measure is not the same so we have to know what we're measuring and interpreting things correctly this is just another sort of a messy slide that talks about how things work the hypothalamus secretes GnRH that goes to the pituitary which secretes luteinizing hormone which goes to the testicles and the Ladak cells then secrete testosterone that's the net that's the basic science lesson of this this again is another one of the basic science things that that the basic science of this it sounds complicated but it is really fairly simple when you get drill right down to it so what happens is that testosterone circulates in our bloodstream and it goes to a lot of different cells in our body and those cells all have these receptors these specific receptors for testosterone the testosterone can latch onto this receptor it that then gets incorporated into this cell and modulates all this stuff that happens in cells in cells of the bones of the muscles of the brain and blood vessels all over our body testosterone has significant effects and and again it's it's somewhat of a complicated process but simplistically speaking testosterone gets to the cells in our body relatively easily and it and and has effect on most cells so what are the direct effects of testosterone muscle mass it improves muscle mass bone formation it helps us make sperm for for reproduction sexual function also testosterone gets converted to this thing called dihydrotestosterone which is really really important that creates facial and body hair it can to some extent create scalp hair loss and balding although that's a this is all different in how testosterone gets converted to DHT from patient to patient it can lead to certain types of prostate growth and function and it can also support erectile function it can also lead to some acne ultimately testosterone again can get converted to the female estrogen like component estradiol which is important for bone health for high density lipoproteins which is the healthy cholesterol which can have an impact on atherosclerosis and estradiol also has some important issues with cognition and verbal fluency so we can thank women as men we can thank women for their hormones that makes us smarter and more fluent and it also prevents dementia and Alzheimer's and some in some respects although that's a little bit more complicated so testosterone gets made by the testicles after all this complicated stuff in the brain and it's sitting there in our body we know that there is both bound and unbound testosterone bound testosterone doesn't work it's latched on to by other compounds that prevent it from doing the things that's doing unbound testosterone is the stuff that acts it's the free testosterone which we can measure unfortunately the assays to measure free testosterone are difficult inexpensive and they're not always done correctly so most of us are not a fan of looking at free testosterone in certain academic centers we can do that but here I don't look at free testosterone very often if I want to look at it it's more of a calculated number than a than a truly measured number sex hormone-binding globulin and albumin both bind testosterone when it's bound to the sex hormone binding globulin most that testosterone is absolutely unusable by the body albumin is a little less tightly bound if you will the what we call bioavailable testosterone that's the stuff that works is the unbound plus the plus the albumin bound and again the sex hormone binding globulin portion may prevent that testosterone from functioning correctly so when I look at somebody the first time around and I'll get into that I look at total testosterone just a baseline total testosterone first thing in the morning fasting for midnight the night before that's the first screening test I get but I don't know I don't get it in everybody I know just every person that rolls through my door I don't order a testosterone I want to know if they have symptoms as well and symptoms are an important part of the whole diagnosis so this again sort of looks at testosterone only 2% of our testosterone is free and and actively available 60 percent is really tightly we call covalently bound and can't be used by the body it can't be incorporated into those cells it can't bind to those receptors and get sucked into the cells and beat and use 38% is albumin bound certain patients the albumin concentration changes it goes up and it goes down and it can alter the the amount of free testosterone or testosterone that's available to the body to function correctly so measuring testosterone levels this is what you just asked about timing is important and I think timing is important from a consistency standpoint so what the American neurological Association states the American Association of andrology which is sort of an aging Association the endocrine Society we've they've all come up with these guidelines so when I see someone who I think has low testosterone I'm pretty adamant about making sure that we measure that first thing in the morning that's before 9 o'clock 7 to 9 o'clock in the morning and fasting from midnight the night before so that timing is important and the total testosterone again may be affected by this sex hormone binding globulin again there are these these assays that can measure free testosterone and total testosterone but not everybody has those assays available to them so we have to have some sort of standard do we go by the endocrine Society guidelines are the ones that we really look at although the American neurological Association recently came up with their guidelines as well so when I have somebody that comes into my office who has who I think as low testosterone or they think as low testosterone we've gone to in some regard this is a relatively new questionnaire that looks at evaluating men for low testosterone it's called the antigen deficiency an aging male questionnaire and this is a series of 10 10 questions that that patients are our are answering for us these questionnaires are ok you know one of the things that we like is objective evidence so if I was seeing somebody with high blood pressure I can measure their blood pressure and it's gonna I'm gonna measure it and that's going to give me a discreet objective number it's a little bit different with with something like low testosterone testosterone has these these symptoms and people interpret these symptoms differently in addition some patients have difficulty with these some patients because of the the printing may be too small they may have some cognitive issues that they can't understand them so we can't rely completely on this and and I do in some regard but not in all patients most of what I get from a symptom standpoint are my direct questions with patients so I don't even like the nurses to go in and talk to patients before I see them because I like to ask the patient's and hear their first responses that's the most sensitive way that I can get an idea of whether I think they are truly afflicted with hypo gonadal symptoms so these are okay but they're not perfect and blood tests are okay but they're not perfect as well if you look at at most of the assays if you got a total testosterone at Holland Hospital they're gonna tell you that the normal range is from about a hundred and eighty to about 750 I don't use that none of us who do testosterone replacement use that number so it's therefore for their own medical legal purposes but I don't I don't use that typically so let's look at the types and causes of low testosterone the number one type is called primary hypogonadism and that's testicular failure for some reason those Leydig cells in the testicles aren't making testosterone and that can be due to infection injury surgery blood flow variety of different things but that's that's called primary hypogonadism secondary is either due to the hypothalamus or pituitary gland dysfunction so that GnRH that first signal that gets secreted by the hypothalamus if that's not working correctly then that's not going to signal the pituitary to signal the testicles to make testosterone likewise if there is a pituitary dysfunction if luteinizing hormone doesn't get secreted correctly that's not going to sync with the signal of the testicles and that's called secondary hypogonadism and that's why in some patience I'll look at their pituitary gland more specifically and occasionally I'll find pituitary disease and pituitary tumors and and other things that are happening in happening in the pituitary gland that needs to be evaluated most often there is somewhat of a combined primary and secondary deficiency there also some unusual congenital meaning born with issues and symptoms and and abnormalities called calman syndrome that can cause low testosterone people are born with that those are a little bit tougher to pick out so what does testosterone do it provides male sexual function and one of the most sensitive indicators of low testosterone when I'm talking to patients is their libido their interest in intimacy men have a strong libido and it's maintained for a long time men that come in and tell me that they're not interested in in intimacy is a red flag that they have low testosterone anabolic anything that's anabolic means building you up building your muscles up your brain your bones your your blood vessels things like that hematological affects basically but that means is testosterone will interact with the bone marrow to make blood vessels this is why the the cyclists in the Tour de France have in the past abuse testosterone it increases their their hemoglobin their oxygen carrying capacity and hemoglobin is normal at about 17 16 or 17 they'll get their hemoglobin is up to 20 and 21 and 22 so they can carry more oxygen it's against the rules and it can have some detrimental effects like stroke so it's a bad thing bone metabolism is there's a huge burgeoning area of testosterone research looking at bone metabolism because what happens as we age as our bones get weaker and what's happening in the population right now is people like to stay active and hip fractures in in people as they age can have a significant problem in their their livelihood and their ability to function mood and cognitive affects mood and cognitive effects are very important when it comes to testosterone that doesn't mean depression moodiness and a depressive mood is important more importantly I think are some of these cognitive effects our ability to do the crossword puzzles and and and and function and read books that we want to read and and maintain our brains in some regard there are definitive insulin and cardiovascular effects that are moderated by testosterone so and we're talking when we talk about insulin and cardiovascular effects we're talking about diabetes heart attack and stroke that's a really important part of things actually testosterone has somewhat a bit of a vaso dilatory effect meaning that it dilates blood vessels so one of the problems with heart attack and stroke is that you're losing blood flow stroke a little different you can have different types of stroke being a lack of blood flow or a bleed but narrowing of blood vessels can be counteracted which normally occurs as we as we age and atherosclerosis and narrowing of those blood vessels that can be offset by testosterone and there is a defined vaso dilatory affect the blood vessels get bigger and flow better blood flows better with testosterone replacement in men who have low testosterone yeah the question is you don't have to have low testosterone of low blood flow no low blood flow can be a multifactorial thing and caused by a lot of different things testosterone may be part of that yeah the question low blood flow cause low testosterone it could theoretically if it's blood flow to the testicles and you're not getting the blood flow you need so yes it could let's look at anabolic effects for a second we know that testosterone increases lean body mass meaning muscles and bones we know that testosterone also decreases fat we know that men men have a tendency to gain weight here in the truncal obesity women are kind of the button thighs I'll see men who have that that sort of characteristic appearance of that truncal obesity and that can be a sign of low testosterone we also know that testosterone is involved with this nastiness here mesenchymal stem cell differentiation basically what that means is that that it can inter intervene and interact with cells at their core meaning there are cells in our body that can become a bunch of different things really important cells in our body and testosterone can have a very positive effect on those cells and that may be related in some regard to certain types of cognitive deficits like dementia and Alzheimer's disease the hematologic effects I talked about before and again testosterone can interact with the bone marrow to create healthy blood blood cells like hemoglobin what we see is this abnormal elevation in blood cells especially when we're replacing testosterone with an injection every two weeks so we have to be cautious in men who I see who I'm treating with testosterone injections I want to be careful and follow their hemoglobin level because occasionally I'll see some elevated levels that need to be things need to be altered a little bit bone metabolism effects there are multiple pathways in with testosterone that affects bone mass and in bone health and again as we age and as we're active we're at higher risk of having issues like hip fractures and and and that can be it can create significant problems we know that estradiol inhibits bone reabsorption so estradiol comes from testosterone you've got to have enough testosterone to have enough estradiol and if they didn't hits bone resorption that just means there are bones are healthier generally speaking there's been a couple of studies that have looked at estradiol levels in men who have had hip fractures and generally speaking there seems to be some some lack of estradiol in those men again this is that hip fracture risk and testosterone levels so very important that I'm interacting with with the orthopedic surgeons and talking to the orthopedic surgeons who are replacing hips and 80 and 90 year old people we want to make sure that they have good testosterone levels I think that can be an AB to them healing correctly after after hip replacement surgery again the mood and cognition I think is really an important issue we know that testosterone improves the positive issues with mood and reduces the negative the effects on Frank depression are unclear there's some active research going on at the University of Michigan looking at depression really careful studies looking at depression and testosterone replacement again cognition is another important thing and helps us live our lives and do the things we want to do as we age to your question a little bit testosterone has a vasodilatory effect it's like a calcium channel blocker we use calcium channel blockers and patients with hypertension the blood vessels are squeezing too much we put them on a calcium channel blocker we open up those blood vessels we lower blood pressure well testosterone has that same effect to some extent and some more significant research is going into this as as we speak as well we know there's an inverse correlation between testosterone levels and cardiovascular risk so as testosterone levels go down the risk of heart attack and stroke goes up we also know like I said before there's a similar inverse relationship between levels of testosterone and visceral fat that's that truncal obesity testosterone levels go down visceral fat goes up there are larger population-based studies that are needed because both of these this cardiovascular risk and this visceral fat are impacted by so many different things that we need these larger population-based studies to sort of ferret things out and figure out what's more important and what's less important there seems to be a growing body of evidence to support the notion that men with lower testosterones are at a more significant risk of cardiovascular disease that's been a recent paper out of MD Anderson down in Texas had some very good date is supporting that there's very few papers that that would suggest the opposite to papers in general as though that we know about what about testosterone deficiency and chronic disease states again the chronic disease states are are common diabetes is a chronic disease state hypertension is a chronic disease state congestive heart failure is a chronic disease State certain types of pulmonary dysfunction prostate cancers is a chronic disease State all of these are important when it comes to testosterone these are our issues that we've we've come in contact with so we know that in chronic disease states testosterone can have a centrally mediated effect so that these disease states will affect our brain which leads to stress and malnutrition use of drugs for pains infections and things like that and these can all have direct effects on testosterone function and testosterone production what about HIV and AIDS now we don't see a lot of HIV and AIDS here but it's a big topic elsewhere when you get to the bigger cities we know that 50% of patients with hiv/aids have diminished testosterone levels the reason I bring this up though is that hiv/aids is is not dissimilar from other types of chronic disease states now you know we used to think of hiv/aids as being something that was relegated to a certain segment of the population and that was a fatal disease it's not really it's now a managed disease it's a chronic disease and it can be it can mimic and some in some senses the chronic disease of diabetes they there there's been some studies that looked at they're very similar in many regards and and what we know is that patients with these chronic disease states are more prone to low testosterone levels which has significant effects on their their livelihood their ability to be treated for these chronic disease states and ultimately their their mortality and they're they're they're like of dying malignancy is another chronic disease state 50% of men treated for malignancies have low testosterone levels so when we talk about men with lung cancer or prostate cancer or pancreatic cancer or colon cancer I think it's really important that we look at their testosterone levels you know we used to say that if men have prostate cancer they can't have testosterone replacement it's it's a contraindication and even says that on a lot of the testosterone medications now but I have a significant number of men who have prostate cancer who I'm giving testosterone to and are doing fine not everyone but a significant portion of them so men with malignancies I think it's really important and I've talked to my hematology oncology colleagues about this I think it's really important that we look at these men and we're talking about treating them we don't just focus on their cancers but we focus on their overall health and part of that is their testosterone levels again cardiovascular disease there was a study done in the Netherlands that looked at low testosterone and a Horta catharsis chlorosis so the aorta is that big blood vessel that comes out of the heart and supplies blood to the rest of our body there was this study showed definitively that men were much more prone to atherosclerosis or narrowing of that blood that important blood vessel if their testosterone was lower a similar study called the carotid artery study showed that narrowing of the carotid artery was much more common in men with lower testosterone levels a narrowing of the carotid artery means you're at a higher risk of stroke we know that testosterone replacement therapy leads to it leads to better exercise tolerance and healthier blood vessels testosterone replacement therapy improves the good cholesterol and it decreases the bad cholesterol bottom line testosterone replacement therapy may be cardioprotective it may it may prevent you from having a heart attack and stroke and and again I think that heart attacks stroke is a multifactorial thing just a lot of things that can play a role in it a part of that though yeah oh well the the problem with with with narrowing of the carotid artery you may have no symptoms until you have a stroke and that's why regular health maintenance and and keeping you healthy is important you know again in the past when I talked about how our healthcare system works it's important now we're looking at outcomes so you as a patient if I'm your primary care physician my job is much it's much more important for me to keep you healthy because I'm gonna be paid to keep you healthy so looking at your carotid arteries looking at your other blood vessels you may not have any symptoms of carotid artery narrowing until you have a stroke so it's important to look at patients as a whole and maybe there are but they can be fairly they can be fairly subtle yeah there's a lot of little things but there's again well there's there's a ton of symptoms that that you might have but again it's one of those things that your primary care physician is going to is going to look at you sort of in the hole and figure out if you are at more risk for for heart attack and stroke so what about the metabolic syndrome the metabolic syndrome is something that we're seeing much more commonly these days and what metabolic syndrome is is a combination of obesity increased cholesterol and sugar loss of the good cholesterol high blood pressure and low testosterone so 25 years ago there was no metabolic syndrome now there's a lot of patients that are defined as having this metabolic syndrome and I see a lot of patients in my practice so I think I'll have that syndrome and those are patients that I key in on it talked to them about low testosterone levels we know that they're based on this Massachusetts male aging study there's an increased risk of metabolic syndrome in men with low testosterone so not the opposite is it's not that you have low testosterone and and you have the metabolic syndrome in Finland men with low testosterone were increased risk of this metabolic syndrome or diabetes so multiple studies have documented benefits of testosterone replacement therapy in this patient population what about prostate cancer so prostate cancer is something that we as urologist see all the time and it's really important to us and this is really an important statement this is dr. collie Carson from Duke University there is currently no evidence that testosterone replacement therapy initiates prostate cancer or stimulated subclinical malignancy to become clinically evident so what this means is that if you have low testosterone and I treat you you're not going to get prostate cancer that's what that means and it means that I can give you testosterone replacement even if you have prostate cancer whether it's been treated or not and that's not in everybody so what's happening in prostate cancer nowadays is that we understand that we overdiagnosis and overtreatment with as far as prostate cancer goes so I have a lot of men who have been diagnosed with prostate cancer who have required no treatment we're just following them it's called active surveillance men in that who are who are with that diagnosis who have low testosterone it's reasonable to treat them and I follow them carefully but it is reasonable to treat them what about prostate size in and PSA we know that as prostate size increases it'd be erotic Lee makes it more difficult for us to urinate and that's that's a reasonable statement we also know that testosterone can affect the PSA the prostate specific antigen which is the blood test that we get to help us screen for prostate cancer we know that testosterone replacement therapy might increase prostate size but I would tell people even with larger prostates who are more who are more prone to urinary symptoms it's okay to put you on testosterone replacement therapy and simply monitor things it's rare that I would see an exacerbation of urinary issues in men with larger prostates who are on testosterone replacement therapy we also need to make sure that we're follow the PSAs and patients on testosterone replacement therapy so this was a small study that was done there were ten patients who had their prostates removed for prostate cancer they underwent testosterone replacement therapy there was no change in their PSA and there was a significant increase in their quality of life and and and that so that's important again I think there's a myth about about prostate cancer and testosterone replacement therapy it's interesting if you look back in the history of prostate cancer there was a physician back in Chicago in the 30s that was a candidate for the Nobel Prize on a number of occasions who showed that we could take testosterone away from men and they thought that that would cure prostate cancer we know that doesn't happen nowadays but now the the pendulum is swinging the opposite way we're understanding that even if you have prostate cancer we can replace your testosterone safely so after prostate removal we know that we follow patients very carefully with PSAs and regular rectal exams we know that we treat testosterone replacement therapy in these men with the least amount of drug that that that ameliorates their symptoms that treats their symptoms and we know that these patients must have symptoms of low testosterone so just because your testosterone is low if you aren't symptomatic that doesn't mandate treatment but we need 5000 prostate cancer patients followed for three to five years to accurately answer all of these questions fortunately there's a big study going on through the university of michigan that's gathering all the all the urology practices together in the state of michigan and we're combining all of our patients so we're getting this data as we speak and we're gonna have more confirm date on this I would still tell you I have no qualms treating patients with a history of prostate cancer with testosterone replacement therapy so bottom line most epidemiologic studies suggest there's no association between das drone levels and the incidence of prostate cancer I will tell you though that I do think that at the time of diagnosis in inpatients if their testosterone is abnormally low they have riskier prostate cancer and most of us believe that nowadays and it has to do with with how prostate cancer grows and develops and if it can grow and develop without testosterone around it's probably a more virulent disease so what about the aging male 5 million men in the United States are hyper hyper gonadal or low testosterone but only again five percent or receiving replacement therapy I you know from my standpoint and from all of our sam points in urology we're much more tuned in to identifying these patients with low testosterone and really focusing on treating them because again i think their quality of life can increase significantly we know that testosterone secretion decreases with age the short-term consequences of that are lot lack of interest in insects and depressive mood like depression is probably the wrong word here the longer term consequences bone loss muscle mass mass issues in cardiovascular risks and again there's this baby boomer population which is really a burgeoning part of the population that we're seeing nowadays and our practice volumes are increasing immensely very much so so there's been a couple of good studies that have looked at the the question is can can testosterone replacement therapy reverse bone loss so there's been a couple of interesting interesting studies that have been done that have measured bone loss with certain types of x-rays and these have been very sensitive x-rays to the quality of the bones and patients with low testosterone and these men have been on a very strict regimen of testosterone replacement therapy and they've been reimaged and the quality of their bones based on these imaging studies have improved significantly so that just means that they have healthier bones less risk of fracture and one of the studies was done primarily in patients with malignancy we're at higher risk of bone loss because of of the effects of chemotherapy so it's a good question the question is would the same thing be being the case with arthritis nobody knows that logically I would tell you that certain types of arthritic changes may be lessened with testosterone replacement therapy in patients who are high pokken adil but those studies have not been done there there's a big push into that simply because of the the amount of people that have been operated on for different types of arthritic issues in joints and in their back and there's there's a study going on at UCLA and in Los Angeles looking at patients who have had back surgery for chronic back pain and have low testosterone and are there ways that we can see better outcomes in these back patients surgery patients that's a good question the question is why are PCP is more tuned in to screening for testosterone I'll defend them a little bit and I'll tell you that I think that there there is busy as they can be their plates are stacked my preference would be that that they talk to patients about low testosterone and send them to me that would be the the way to go and not from a monetary standpoint because I'm as busy as I can be right now but I have a focus on this and I think I can better evaluate and treat these patients I think they're gonna focus on the things that are more crucial your your diabetes and your blood pressure and your cholesterol but they have so many things to look at on a daily basis with every patient that there's a point in time where things become somewhat limited and and I think it's also if you look at the Affordable Care Act and what the Affordable Care Act is doing you know I would defend the Affordable Care Act in some regard in that I think the push there is to look at outcomes so right now nobody looks at my outcomes at all if you come to me and I operate on you there I get paid to operate on you nobody looks at my outcomes that's changing the the primary care physicians are now being more graded on their outcomes more more stringently well you know and and again what what what I think is really important is that you need to be your own advocate and you need to push the buttons and say I need this unfortunately the healthcare system is what it is it's going through these big changes right now I think a lot of the changes are good some of the changes are not good but keeping patients healthier is the point of things it should be the point of things fee-for-service medicine which is what we've had forever really didn't matter it did it wasn't what wasn't focused on keeping patients healthy I think that's changing yeah I again I think the PCP is do a really really good job I think they're as busy as can be again a you know we're trying to set up a system in Holland where we have this integrated healthcare system where I collaborate with my primary care colleagues and with the cardiologists and with the endocrinologist and with the cardiovascular surgeons and the orthopedic surgeons to keep people healthy that's our charge that's what we should be out here for that's why I'm standing up here I now don't get paid to stand up here and talk it's I think this is an important message that to the community that people understand stuff like this it's it sounds complicated it really isn't complicated but ultimately it can go a long way to keeping us healthy I mean I'm aging too so I want to keep myself healthy I want to I want my my family to be healthy we are we no I think again I think a big part of this is the the primary care physicians doing what they prioritizing things and doing the things that that are important for them they can't they can't do everything there's there's also a lot of misinformation about testosterone there's a lot of primary care physicians that think it's a bunch of nonsense and I don't believe that at all and and that is still being sorted out to be honestly you know I'm a big proponent of it I think it can keep us healthy and it's a very important thing to look at you know as my wife would say doctors are occasionally right but never unsure and that's how we are we we we think we know everything and we don't know everything and sometimes a little humility goes a long way so it's a good questions going here so why do only 5% of hypo gonadal men's receive testosterone replacement therapy so this is sort of a timely slide so we like to blame the patient's I hate going to the doctor but the patients are part of the issue doctors are part of the issue symptoms are a normal part of aging that's doctors I think that's what was said to you right incorrectly assessed or not assessed at all again we get the testosterone level drawn at Holland Hospital and the proud comes and it says the normal range is 180 to 700 and your testosterone comes back at 200 that's normal no it's not less than 300 is that is abnormal so there's got to be some consistency there there are perceived risks of testosterone replacement therapy prostate problems and these cardiovascular things that again if I can give you a stack of papers this hot this high that would would support these are peer-reviewed academic papers that would support testosterone replacement therapy looking at things like cardiovascular disease there are two papers that say the opposite one is from the VA and that should tell you enough the VA paper was was a monstrous joke there were women involved in this testosterone replacement therapy that never got testosterone there were patients that had never filled their prescriptions it was really a bad study the other one I referenced earlier the journal the American Medical Association so let's talk about treatment what are the goals the goals are all of these things improve libido mood feelings of well-being muscle mass bone cardio productive contraindications we talked about breast and prostate cancer you know large prostates sleep apnea congestive heart failure this is probably the only thing that from my standpoint is a contraindication to giving testosterone replacement and that is an elevated blood count that hemoglobin level is too high I think there's good studies that show that sleep apnea is improved with testosterone replacement therapy I rarely see prostate problems urinary problems in men who are on testosterone replacement therapy the you know obviously breast cancer doesn't occur in men or occurs rarely prostate cancer is not a contraindication in my mind to replacing testosterone without a doubt what let's just focus on sexual function it's a difficult subject for some people to talk about but it's something that I think is really important again I would tell you that there's many good studies that show that men with erectile dysfunction are at higher risk of heart attack and stroke I wrote a paper once that said erectile dysfunction can save your life and it can and I've had patients where I've who come into me for erectile dysfunction who we diagnose heart and significant heart disease on what are the facts we know that lower testosterone levels diminish interest in saks libido diminished spontaneous erections those morning erections and night erections that we get are very important keeping things healthy they're really important loss of those erections can lead to significant problems we know that testosterone replacement therapy has central and peripheral effects in our body as far as sexual function goes we know that in testosterone replacement therapy there's an increased frequency of sexual thoughts and desires and that's a normal part of things all of this stuff is what is in in some regard is is positive and good when it comes to testosterone replacement therapy and sexual function one myth though testosterone replacement therapy is a primary form of treating erectile dysfunction it's not it's a supplement in some regard but it's not a primary therapy things like viagra and levitra and Cialis and injection therapy and penile implants or primary therapies testosterone is not so let's look at testosterone replacement options these are the options in you've come to me we've talked about your testosterone you've got symptoms of low testosterone we measured your levels they're low we figured that you had sort of this combination of a pituitary problem and a testicular problem and we're going to talk about test testosterone replacement therapy right now a lot of testosterone replacement therapy is governed by the insurance companies the insurance companies gonna tell us what we can and cannot do that's that's somewhat of a reality because they're gonna pay for things I think that the transdermal gels so this is a tube of a gel that you can rub on your shoulder or chest your inner thigh or under your arm on a daily basis I think that's the most physiologically normal way to replace testosterone you got to do it every day you can get it on your partner which you don't want the insurance companies don't pay for this and they're in the the pharmaceuticals know it and they've jacked the price up and it's exorbitant so what happens is that everybody really starts off with injection therapy so you get a shot in the butt every two weeks and what I do is I have you get these shots every two weeks over the course of about ten weeks and then we recheck your levels why a week after an injection halfway between it's really important to do it that way and in time for your sixth injection you come back and we talk about your symptom response and I look at your your your laboratory responses I look at your testosterone your PSA blood tests and your haemoglobin and that's how we start out in most patients transdermal patches these are these patches that we put on people those have fallen by the wayside and I can people get these welts and they look like they've been attacked by an octopus they itch and they're they're really a problem so I'm gonna back buckle discs this is a little it's almost looks like a little piece of cardboard that you put on your gum and the testosterone is absorbed the majority of those patients ended up with significant gum irritation and nobody uses those anymore oral preparations are a no-no you can get them elsewhere in the world but what happens is that they get transformed these these medications that you take orally you swallow they get transformed but by your liver and they create liver tumors that's a problem the subcutaneous pellets are a reasonable option that's where I put a series of pellets underneath the skin on your buttock it takes about five minutes to do it and it can last six to nine months there is a newer injection in the United States now the the standard injection lasts two weeks there's a newer injection that lasts ten weeks it's been around in Europe and Canada for 25 years all of my Canadian and European colleagues when I go to meetings and talk to them they all use the ten-week injection it's not it's not well thought of here it's the when the FDA approved it they approved it at a lower dose I've had a number of patients that have been on the medication and they don't respond very well to it so it's not a great option unfortunately so I went through all of those this is the every two-week injection that we use most probably about 75% of the patients in my practice are treated with this I can teach them to inject themselves at home we still have to monitor them carefully though and they've got to get regular blood tests a lot of patients will come in and they don't want to do it on their own they'll come in and get that done in the office this is not approved in the United States it's it can be used in Europe and Canada this is the longer-acting substance which again is is a good option unfortunately it it said it's at a suboptimal dose again these are the patches that we don't use anymore the gels I think are the best option but they're very expensive very very expensive the buccal disks I talked about the test-tube LR the subcutaneous pellets so kind of wrapping things up here I know that we've gone a little bit longer we know that testosterone is the primary male androgen the antigen is the thing that builds us up we know that low testosterone hypogonadism a very prevalent issue five million people are affected it's probably triple that to be honest with you I think or even more short and long-term effects of low testosterone can be significant the assessment very straightforward treatments are varied and again very straightforward there's a lot of different options for treatments and right now I would tell you that without a doubt treatments have six have very except acceptable risks and the upside of treating patients significantly is is greater than the downside risk and probably there's a bigger downside risk to not treat not being treated I'm more than happy to answer questions I'm gonna stand up here for a little bit I appreciate everybody's attention and I appreciate the questions and hopefully this is this helped you with some some issues with low testosterone yeah you do this is just a replacement therapy and again I think there's a lot of research going on into a better options for longer-term replacement therapy so you don't have to come in every weeks you know one of the problems with the every two week injection is you get a big burst of testosterone and trickles down over two weeks it doesn't really do that it's a little bit different but that's not a physiologic way that testosterone is is released in our body remember we get a little bit of a burst in the morning and it trickles down over the day that's why the the gels are a better way to go what you got to put it on every day and you can there is transference if you don't rub it in and you put it on before you go to bed and you're you know hugging your wife you could you could she could wake up with a mustache kind of yeah yeah the the pelts are a little bit different i I liked the pellets I don't think there's as vigorous or response to the pellets as there are to the every two week injection I think people get a more vigorous good feeling with the injections but the nice thing about the pellets if you reach a steady state on the pellets and we know that you let's say you were in every nine month pellet person I have a lot of patients like that I see them every nine months and I get a blood test essentially a couple of months before they they come in and I know where they're at and it's pretty easy so it's easy to follow yeah it's not going to come down for a while the the pharmaceuticals know that I'm out there doing this they like this because I'm talking about this stuff that they make I don't have any association with any of the pharmaceuticals I don't I don't talk for them I don't I don't I don't like to see them in my office to be honest with you I think they're they're there on the one hand sales people but they provide an important service it's just that they are very much into a profit motive and when they see things like this they jack the prices up and they they're expensive it's not coming down anytime soon the other thing though there are compounding pharmacies that are starting to come out with a cheaper version of the topicals that they make themselves there are some issues with compounding pharmacies and safety with some infections that occur the past so some of the compounding pharmacies went away but some of the compounding formulations can be good we could see a rise in those in the market yep yeah absolutely Perico is one of them and Perrigo does ago I think a good job with some of the generic stuff so yeah again I can I can give you a stack of papers this high that would say that just the opposite there are two papers that would suggest you're at higher risk of heart attack and stroke with testosterone replacement and both of those papers are remarkably poorly put together so I'm a proponent of it yeah Blue Cross Blue Shield made some changes but what the what the insurance companies do is they make some changes and they make it a little bit more difficult and a lot of physicians and patients kind of give up and the farm the your your payer says no we say okay but if they say no and we say wait a minute we send letters and we bug them they'll say yes it's a good question yeah I think there is the problem is that there are no studies that would confirm that and with all the natural supplements the studies haven't been done and so you don't really know and I wouldn't say no you shouldn't do that I would say to you the only downside of doing it is your well is the is your out-of-pocket cost singer and you're guessing so yeah it's a great question I have a lot of patients that get medications from the Canadian pharmacies and most of the patients that I that I see that that do that are patients looking for things like viagra and levitra cialis I have rarely had patients have problems with those pharmacies and those pharmaceuticals again there are no studies that would would show that to be effective or is there any proof of its efficacy but I do think there are some natural benefits that that we we can get from those remedies it's just that there's no studies that that would confirm or support those well III would tell you that you know one of the things that we need we we need a well-balanced diet you know clue cholesterol is the building block of testosterone so you need cholesterol cholesterol it's an important substance in our body you know fresh food is really important I think processed food is a really bad thing I think foods with high fructose corn syrup and those simple sugars are bad those are the things that simulate our pancreas and create pancreatic problems and diabetes and fat related issues that's more important I think and and ultimately that's going to have some impact on on testosterone production no it won't lower your testosterone no because there is and and and I think that's a good question you need a certain amount of cholesterol to build on and to make testosterone but you will have that regardless of how low your tell your cholesterol goes so no you didn't calcium being bad for you no what what what well I think what you're referring to is that testosterone it can act in some regard like a calcium channel blocker so calcium channel blockers are given for people with higher blood pressure and certain types of heart problems it increases blood flow because it can allow more blood to get to the certain organs and testosterone has a similar effect on the blood vessels as as do calcium channel blockers yeah Medicare is the same thing Medicare is restrictive and Medicare and supplemental Medicare's are are restrictive most of the Medicare patients are not going to be able to qualify for the topical agents we if you're referring to to treatment yeah treatment most of the most of my Medicare patients are being treated with the every two-week injection so yeah you know insurance this can be fickle though and they can have little little things that they exclude so you have to be very careful when you talk when you have your insurance policy you know if you have to know what's what's covered and what's not covered but I fight with the insurance companies all the time regarding a bunch of different things and I have all these form letters that we just type out and sign and we badger them and I call priority health all the time I know the medical directors there I'm sure they roll their eyes when they they see me on the phone and it's not I'm not nasty about it's just you know it's sort of like the squeaky wheel if you if your firm and dispassionate you can get things done just it's it's a time-consuming issue I think in many cases depends on him I think there's some primary care guys that like to stay in control and do things and I'm very supportive of that likewise I'm supportive of those that say I'm going to take care of your your diabetes and your high blood pressure and your heart disease and your cholesterol and I'm going to let blood load do the testosterone stuff no once a month is wrong yeah I see that a lot once a month the injection of the testosterone sip unit is not adequate if you if you you'll get a blood test at two weeks and you'll be completely low so it's now and I would I'll step back a second and I would tell you that as soon as I say that will always happen or never happen I'm wrong there are some patients out there that probably function fine on a monthly injection I have a couple guys on a monthly injection but the vast majority of patients needed every two weeks and I can show you the data I can show you the data for my patients to prove that so you don't you can call the office and we're you know that that's a nice thing about healthcare nowadays you don't need referrals you shouldn't if you want to come in and see us we're more than happy to see you it's not that long you know our our goal there's four of us in this group I do most most of the testosterone stuff comes to me but you know our goal is not to have people waiting six weeks to see us our goal is to see patients promptly and we're pretty good at doing that and if it's if if things happening you need to be seen be the squeaky wheel just come in and we'll get you in nobody it's the wait a long time well if I saw you today and and we talked about low testosterone I thought you had symptoms of that I would get a blood test tomorrow morning theoretically that comes back in 24 hours the guidelines are pretty strict about saying if your testosterone comes back less than 300 we need to confirm it with a second and the insurance companies are sticklers when it comes to that so what I do if your let's say your testosterone came back at 220 I would have you a few days later get a second testosterone and a luteinizing hormone it tells me what type of low testosterone you have and theoretically the next day we could treat you you can do it you can do this in less than a week it's pretty pretty quick yeah that's a good question so what happens when you get exogenous testosterone meaning you get a shot in the butt or you get a the gel or the pellets what that does is it sends a signal to the pituitary gland to decrease the luteinizing hormone or the luteinizing hormone is the thing that goes to the testicles and says make testosterone so that gets suppressed there's a small percentage of patients where that suppression will be long lasting so that once you stop the exogenous testosterone there is the chance that your normal level of testosterone or your tip of the level of testosterone won't come back that that happens relatively infrequently but it can happen there's also an option for instance if I have a 25 year old who has low testosterone for whatever reason I won't treat them with a exogenous testosterone I'll treat them with a substance that stimulates their pituitary called clomid and that's always an option I did include that up here but that's always an option that maintains sperm function and and production and maintain it all it does is stimulate the testicles but it really has to be somebody that has a testing of primary hypokinetic diagnosis so that's something I always talk to patients about it's it's an important adjunct to things no no that's a physiological yeah your libido right you know men have a strong libido we know that we're men are raring to go and that's a reflection of their testosterone and libido is one of the most sensitive indicators of a low testosterone when I have men that come in and I ask them specifically are you interested in in intimacy and they say well kind of that's a red flag right there so sometimes you have to dig into that a little bit more to to figure that out because there can be some other psychosocial issues going on in relationship issues and when I see patients with sexual dysfunction whatever it may be my preference is to see couples because I think all of that is a couple's issue and it's much more effective in me to from the standpoint of evaluating patients correctly in treating patients correctly to see both partners it works much better that way you know it can be a sensitive emotional issue not many people like to talk about it I see a lot of patients with sexual dysfunction you know what I would tell you is that we want to live our lives with people want to maintain their intimacy they want to they want to do the things they want to do they don't want to say well I'm 65 years old I'm I'm done that mindset is falling by the wayside anything else well thanks everybody for coming I appreciate it and if you have questions you can always call the office I'll talk to you over the phone if you if you have questions about something you don't need to be a patient if you have a question about something leave your name and number in the office I'll phone you back it's it's a good you know one of the great things about how I spent a lot of time in Grand Rapids in Grand Rapids is its spectrum Holland does a really really good job it's a smaller Hospital I think it really really appeals to the community and our goals to keep the community healthy so thanks everybody for coming appreciate




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