TRT: Troubles and Challenges

“Do you feel tired?” asks the silver fox in his outdoor jacket, wind in his hair. He then suggests that you may suffer from low testosterone, which apparently is a serious condition that could be impacting “millions of men.” 

Evidently the solution, he suggests, is just a prescription drug away. Next time you hear an advertisement like this, there are several things to keep in mind. 

First: the American medical association has called for a ban on direct to consumer advertising from pharmaceutical companies. 

Second: the list of explanations for feeling tired or experiencing mood changes is looooooong, and testosterone levels are typically pretty low on the list. 

 But third and most importantly, is questioning what is considered “low” testosterone, why does it matter, and how is it assessed?

Most US males, whether silver foxes or dad bods, will see their testosterone decline with age, dropping around 1-3% per year after the age of 30. 

Testosterone prescriptions are on the rise (more than a three-fold increase in the last decade), but many questions remain about whether age related declines in testosterone require treatment. Some studies even suggest there are risks associated with testosterone treatment, including increased heart attacks and strokes though there is not yet sufficient data to make a conclusion either way. 

 In the 1990s there was an increase in prescriptions of hormonal replacement therapies for post-menopausal women without long term studies on their efficacy or safety. Post-menopausal hormone replacement therapies were intended to prevent hot flashes and increase bone density but also resulted in increased risk of breast, ovarian, and endometrial cancer for millions of women. 

When a large, long term study examining the efficacy and safety of menopausal hormone replacement studies was finally conducted (The Women’s Health Initiative), it was halted prematurely because of high rates of breast cancer.

What is testosterone? What does it do?

Testosterone is an anabolic steroid, and helps build muscle mass. As Hans and Franz would joke on SNL, testosterone is here to “pump you up.” Testosterone (T) also affects behavior in humans and other animals; elevated T is associated with increased risky, aggressive, or mate-seeking behaviors while inhibiting parenting behavior.

Ok, so testosterone could help weight lifters and athletes–why would doctors be prescribing it to older men?

The vast majority of older men probably are not trying to become body builders, so on the surface prescribing exogenous testosterone (a DEA Schedule III controlled substance) to older men appears puzzling. 

Some research suggests that men with very low testosterone production are at increased risk of dying. Men with the lowest levels of testosterone are at the highest risk of mortality in several longitudinal studies. But my Pavlovlovian “correlation does not equal causation” response from Stats 101 compels me to unpack “does low T cause death?”

Some of the most influential testosterone research has been conducted in avian model systems (before you cry fowl, the early studies of testosterone production were conducted in chickens). In birds, healthy males in good condition can maintain higher levels of testosterone than sicker males in poor condition. 

The effects of high testosterone costs calories; building and maintaining extra muscle tissue is expensive, as is fueling aggressive behavior and mating activities. Mate guarding behavior and fighting other males to expand territories takes precious time and energy. An organism has to make sure that testosterone is not writing checks that the body can’t cash. 

In many avian species, males have testes that regress at the end of the mating season, dropping testosterone production dramatically. This frees up time and energy that can then be spent on parenting existing offspring as opposed to seeking out new mates, or that can be invested in survival and immune function. This is a classic life-history trade-off. Like any finite resource, calories spent on one activity can’t be allocated to another.

Investing in time and energy raising offspring, or invest that time and energy making new offspring- everything has a trade-off. 

Males who are sick or injured have to allocate their finite caloric resources in immune function and tissue repair, so that energy can’t be invested in muscular development and aggression. As a result, testosterone is decreased so that energy stays focused on immune activation and survival. 

In this way, testosterone is a bit like a switch. When times are good, invest in bigger muscles or fighting for a larger territory to increase reproductive success. When times are tough, prioritize survival.

Men aren’t birds, but endocrine systems are amazingly conserved among animals. Many of these hormonal pathways are evolutionary ancient. 

Among men, naturally occurring decreases in Testosterone happen during the transitions to marriage, and parenthood. And as found in birds, Testosterone regulation in men is sensitive to energy balance and health condition. 

If a man in the United States fasts for a few days, testosterone drops dramatically. In adult human males, ~20% of resting metabolic rate is dedicated to maintaining muscle tissue. If a man is not getting enough calories to support that muscle, testosterone decreases as the body prioritizes other expensive tissues such as the brain and intestine. Even skipping a single dinner results in significant reductions in testosterone the next morning! 

 Energy balance is not just energy in, it is also energy out, so if a man is burning more calories than he is consuming then testosterone levels go down. US Army Rangers have testosterone levels nearly as low as castrati during peak training when they burn up to 6k calories per day on little food and less sleep.

Energy balance- calories in, calories out- is not the only part of the equation. Getting sick triggers mobilization of the immune system, which can be quite costly energetically. Almost immediate decreases in testosterone occur with major illness. Minor infections result in decreased testosterone, and even a flu shot is precipitates short-term testosterone decreases.

In short, any time there is an energetic shortfall­—not enough food, too much exercise, or illness— there is an immediate decrease in T.

What is a “normal” level of testosterone?

Since testosterone is responsive to environmental conditions, what does this mean for “normal” levels of testosterone? 

 Testosterone levels in the US and other industrial populations are dramatically higher levels than in subsistence populations. For young men the differences are even larger, with studies among Amazonian hunter-gathers and forager-horticulturalists showing levels of testosterone 30-40% lower than age-matched US men. 

Lower levels of testosterone are reported in subsistence populations around the world, from Bolivia to the Congo, Paraguay, and Nepal.

In industrial populations, we can hunt and gather 20,000 calories at McDonalds without getting out of our car. 

 In the US, infections with parasitic intestinal worms are rare and illnesses are quickly treated by medical professionals. For 99% of human history this was not the case; food security was a constant struggle and parasites and pathogens were commonplace. 

 With low food resources and high parasite load, testosterone is immediately down-regulated so it’s no surprise that nearly every subsistence population examined shows significantly lower levels of testosterone compared to US males. Not only is testosterone significantly lower in younger ages in hunter-gatherers and forager-horticulturalists, but it also appears not to decline as much with age, if at all.

Testosterone levels: Are subsistence populations low or are industrialized populations high?

It’s not that subsistence populations have low testosterone; instead they have calibrated levels of testosterone to the environment they are experiencing. Free of environmental insults and with nearly unlimited calories available, US males can achieve very high levels of testosterone in their early 20s due to their evolutionarily novel environment. 

Post-industrial life has relieved many energetic trade-offs. We have plenty of easy calories to invest in both immune function and high levels of testosterone, clean water largely free of parasites and pathogens, and illnesses are treated rapidly with antibiotics. All of these factors create a situation where US males can achieve high levels of testosterone at young ages, but could simultaneously create their own risks.

Drawbacks of high testosterone

Beyond the potential behavioral impact of testosterone supplementation on aggression, there are some long-term physiological consequences of high testosterone. 

Among industrial populations, prostate enlargement in aging men is thought to be a universal; if men live long enough they will suffer from benign prostatic hyperplasia. While not malignant like prostate cancer, 90% of all US men in their 80s suffer from prostate enlargement, which can compress the bladder and urethra resulting in difficult, painful, or frequent urination. 

 The prostate is lined with testosterone receptors, and exposure to testosterone can increase prostate size; the front line treatments for both prostate enlargement and prostate cancer involve medications that reduce circulating testosterone (and other androgens). Indeed studies suggest men with higher levels of testosterone are at higher risk of prostate cancer. 

 Subsistence populations under energetic constraints with low testosterone levels, like rural peasant farmers, and Bolivian forager-horticulturalists show remarkably low levels of prostate enlargement. 

Even among subsistence populations with lower testosterone, there is still an association between testosterone and prostate size- men with higher T than their peers have larger prostate sizes.

Getting juiced

There are not yet any long-term or large-scale trials in the US examining associations between testosterone supplementation and risk of prostate enlargement or prostate cancer. 

Studies in animal models suggest that testosterone therapy does increase the risks of prostate cancer. There also appear to be some cardiovascular risks in humans, but systematic long-term, large-scale studies need to be conducted. 

 This means that similarly to post-menopausal women who received hormone replacement therapy in the 1990s, men getting testosterone treatment are effectively a large quasi-experiment, the results of which are yet to be known. Certainly there are reported advantages of testosterone therapy on muscle mass, bone mass density and sexual function, though not in the frequency of sexual activity.

Until we have good long-term data examining the full consequences of Testosterone supplementation, we will not completely know whether these advantages outweigh the risks. 

And very importantly, a large portion of men getting treatment may not actually qualify for treatment according to American Medical Guidelines- in fact, 25% of men getting testosterone treatment in the US had not ever had their testosterone tested. 

Worse yet, a recent FDA report indicated that “only about one-half of men taking testosterone therapy had been diagnosed with hypogonadism.” In the UK, testosterone prescriptions increased by approximately 90% between 2000 and 2010, while the diagnoses for clinically low testosterone increased only 1.1%.

Get a juicer

Recent studies suggest that a potentially important source of age-related decline in testosterone is from increases in body fat. When testosterone interacts with fat tissue, it converts into an estrogen, which promotes the deposition of abdominal body fat in men. 

With higher fat stores there is an increased probability that testosterone will convert to estrogen, creating a feedback loop that can promote obesity. Large-scale studies reveal that men with more body fat show faster decreases in testosterone with age. 

Studies of weight loss following gastric bypass show testosterone nearly doubled in the two years following surgery. Non-surgical weight loss among previously obese men significantly increases circulating testosterone. So while caloric restriction can result in decreases in testosterone in healthy men with relatively low body fat, decreasing body fat in overweight men can result in significant increases in testosterone. 

With 74% of adult males in the US considered overweight or obese, men might consider putting down that slice of pizza before picking up a prescription for testosterone.

So who needs testosterone treatment?

Regardless of what an online quiz suggests, only a doctor can decide if you have clinically low testosterone (and guidelines from the Endocrine Society suggest only after repeated blood tests). At the end of the day, it is important to remember that (barring any testicular injury/pathology) low testosterone often means that there is an underlying problem such as illness, obesity, or another inflammatory process. 

The decrease in testosterone is just a symptom of these underlying issues- like a canary in a coal mine. The body is calibrating testosterone to a level that is appropriate for current circumstances and condition. 

Circumventing this and adding extra testosterone when the endocrine system is actively trying to downregulate testosterone may be fighting against a body’s own physiology. 

 Testosterone is not a miracle drug or fountain of youth; overriding several hundred million years of vertebrate endocrine evolution may not be the clearest route to better health.

Facts About Low Testosterone

Your energy level is down, you’re putting on weight, your mood is affected and your sex drive is decreased. You might have low testosterone. Ads for testosterone therapy flood the television and it looks pretty easy to get. Should you get it?

Dr. Tom Miller from the University of Utah tells you the facts about testosterone treatments and why some men may need it. He also discusses the reasons it may not be the best solution for other men, and why he advises against ordering testosterone treatments online or through the phone.

Interviewer: If you watch any TV at all you can't escape the ads, ads for you need testosterone therapy. It looks like it's pretty easy to get, but should you get it? That's the question. Right now I've got with Dr. Tom Miller, University of Utah health care.

Dr. Tom, for a guy that's over 30 years old, it's been scientifically proven that testosterone levels start dropping at that point. Should I be ordering some of this testosterone online? I mean after all, I want to look like that guy.

Dr. Tom: I think the question, Scot, is why do you think you need it? What's different?

Scot: So, the ads tell me my energy levels have dropped, which they have, that I start putting on more body weight, that my mood is affected, and my sex drive is decreased. Testosterone is going to cure it. It's kind of cure-all is what they're telling me.

Dr. Tom: That's a great concern. That's a concern of many men, and women, throughout the country, but the real question is are there different causes for those things you mentioned? There are many causes for people being a little overweight, feeling a little fatigued. It isn't just testosterone; it's a whole basket full of causes.

Scot: So, if I came into your office, and I gave you those symptoms, and I said that I want testosterone what would you say to me? Where would you start looking?

Dr. Tom: I would ask a few questions. One I'd ask, "What's your sex drive like? Has it dropped off? Are you interested in sex? Do you have the same drive that you had five years ago?" And if the answer to that is no and that you were concerned about it, I'd then go ahead and measure your testosterone level.

Scot: Okay.

Dr. Tom: But I'd also ask you a number of other questions. If the testosterone levels came back low, then we might do a trial of testosterone replacement, and we would then monitor how you felt. Did it make you feel better over the course of time that we try the medicine? If not, it might be wise to stop it.

Scot: So, let's back up for a second, these ads that I'm seeing on TV, I can just order without a doctor's prescription?

Dr. Tom: No, you have to have a doctor's prescription. There's a doctor on the other end that's asking a set of questions.

Scot: So, when I make that call, there is a doctor?

Dr. Tom: There's somebody that has to write the prescription.

Scot: Got you. How do they know how much I need, because it sounds like you would do tests to find out what the actual level is? It sounds like they're just asking me some questions and if I pass they're going to write me the prescription.

Dr. Tom: That's probably true. I can't attest what other things that they do, I'm not sure that's the best way to get health care. Basically you're telling them that you need testosterone, and they're saying, "Fine. Answer these questions. Here's your prescription." I'm not sure that's the best way to try to define what your problem is. As I mentioned before, the causes of fatigue and weight gain there are multiple issues related to that not just testosterone.

Scot: So, let's pretend that I come into you because I want to be a little smarter about it. You ask me some questions; you decide to run some tests. You find I'm in the normal range, on the low end of the normal range. Would you do anything at that point?

Dr. Tom: I probably would counsel you about your lack of sexual drive. Well, I'd seek more information about that, and it might me that there are other reasons for that aside from the fact that the testosterone is in the borderline range. I suppose if you really wanted to try it we could do a trial.

Scot: Sure.

Dr. Tom: I'm not opposed to that if the patient thinks that's right, but I try to give them a realistic expectation. Also tell them that, "Look, it's not a wise thing to take medicine if we do this for several months and you find there's no difference, and you're honest with yourself about it." Just as with any medicine, in my mind, it doesn't make sense to take it if you really aren't getting a benefit from it.

Scot: So, let's take a look at these ads; they promise me so many things. Let's talk about the benefits of testosterone therapy, just from a strict benefit. Why would I, as a man, even come to you and talk to you about it?

Dr. Tom: Certainly, if you had low levels, it might be affecting your sexual drive, you might have some fatigue, you might have less muscle mass then you were used to. In that instance, if you were replacing testosterone, it might help you quite a bit; you might have a great improvement. The problem though, long term, is we don't really know if the side effect . . . we don't know what the side effects are of testosterone replacement over the long haul greater than five years. We just don't know that yet.

Scot: So, this is kind of the risks part right now, is we don't know what the risk are.

Dr. Tom: We don't really know what long-term risks of testosterone use might be, replacement. There are a number of men that I know who have low testosterone and they don't notice any difference. So, do you replace testosterone by testing for it in men who are low? The answer is I don't think we really know. We don't have enough information. We do know that testosterone helps maintain bone integrity and strength but we're not at the point where we say screening for testosterone is a thing to do.

Scot: So, it falls off as I turn 30, and as I get older. When you're testing, are you testing for the normal range for, say, a 55-year-old man, if I'm 55, or were you...?

Dr. Tom: I want to back you up a little bit; testosterone may decrease variably in men so it's not the same as menopause in women.

Scot: Okay.

Dr. Tom: So, when women enter menopause their levels of estrogen drop precipitously. The same is not uniformly true in men. Some men have lower levels of testosterone over time, but not all. So, it's unclear which men would have low testosterone and others have normal testosterone; we just don't know yet. There's not a recommendation to screen all men for testosterone levels.

Scot: So, you really can't say how much should a 50 year old man have?

Dr. Tom: Well that's correct, I mean because we don't screen.

Scot: Got you.

Dr. Tom: We don't test for testosterone as part of an annual exam in the same way that we test blood pressure or test cholesterol or test blood sugar.

Scot: So, your advice is don't order the stuff on TV because you're playing with something that...?

Dr. Tom: My advice is that if you have questions about the way you feel, whether you have fatigue or decrease in energy level or a decrease in your sexual drive, then you should probably talk to your physician about that and decide if testing your testosterone level is right for you. Nothing wrong with that.

Do You Have Hypogpnadism (low T)?

Overview - What is Hypogonadism?

Hypogonadism is a condition associated with low serum testosterone levels and symptoms such as fatigue, decreased libido, weakness, and weight gain. It is known to occur with aging, as most men have declining testosterone levels beginning in their 30’s. 

Low testosterone levels have been associated with decreased muscle mass and strength, osteoporosis, depression, decreased cognition, ED, and metabolic syndrome. Testosterone replacement therapy (TRT) has been shown to increase lean body mass, improve bone mineral density, increase cognitive performance, and improve sexual function.

Diagnosis and Treatment

Currently, there is no single consensus statement regarding diagnosis and management of hypogonadism. 

In general, the diagnosis requires a low serum testosterone level coupled with at least one clinical symptom of low testosterone. Absolute ranges of normal testosterone levels are difficult to establish. Therefore, treatment is generally geared toward improvement of clinical symptoms rather than an absolute serum testosterone level.

Historically, the concern for TRT was its effect on the prostate. Despite evidence that the prostate does enlarge slightly on TRT, no studies have shown any significant worsening of urinary symptoms while on therapy. 

Studies have also demonstrated no significant change in PSA while on therapy. An increasing PSA while on TRT may indicate underlying malignancy and warrants evaluation. 

There has been no increased risk of prostate cancer demonstrated with TRT. Additionally, studies have demonstrated no increased risk of recurrence in men on TRT after undergoing treatment for prostate cancer. Small studies of men with active prostate cancer have shown no progression of disease on TRT.

There are many options for TRT, each of which has its benefits and disadvantages. The decision about which one is right for you will depend on your personal preferences and a discussion with your physician. 

 In some cases, different insurance companies may cover one option and not another, which may also be taken into consideration. If the desired effects are not achieved with your initial choice, a different option can be tried to see if it is a better fit for you. A summary of the most commonly used TRT options is provided below.

Topical Gels: Advantages include more constant levels with daily dosing, high patient satisfaction, and avoidance of needles. Disadvantages include increased cost compared to injectables, the potential for transference of the gel to others (e.g., spouses and young children) through contact with your skin or clothes, messiness of gel application, and potential skin irritation. 

Injectables: Advantages include efficacy and patient satisfaction, weekly to biweekly dosing, and low cost. Disadvantages include increased fluctuation (peaks and valleys) in testosterone levels compared to daily dosing options and the requirement for needles and self-injection.

Implantable: The advantages of this therapy include convenience and decreased frequent of dosing. As this requires a short office procedure, there are risks including bleeding, infection, and pellet extrusion in less than 1% of cases.

Monitoring

Regardless of the type of testosterone replacement therapy chosen, you will need to be monitored at regular intervals (usually every 3-6 months); both to confirm good control of your symptoms and to ensure that there are no potentially dangerous side effects. The follow-up regimen usually consists of the following:

• Physical examination, including digital rectal exam to rule out prostate nodules (yearly).
• Routine blood work for testosterone levels and other hormones (every 3-6 months)
• Routine blood work for lipids, hemoglobin and hematocrit, and PSA (prostate-specific antigen) (every 6 months).

Testosterone Therapy and Human Growth Hormone

As discussions around performance enhancing drug scandals, doping and potential multi-game suspensions continue to plague Major League Baseball and some of its top talent; Health Talk recently talked with U of M experts about how human growth hormone (HGH) and testosterone actually affect performance.

We sought out University of Minnesota College of Pharmacy pharmacology and drugs of abuse expert David Ferguson, Ph.D., and Bradley S. Miller, M.D., Ph.D., a pediatric endocrinologist with the University of Minnesota Medical School who has studied growth and development associated with HGH.


Can HGH and testosterone be considered performance-enhancing drugs?

Definitely. Testosterone is listed in the textbooks for performance enhancement and HGH, while newer to the game, is also listed. Football, baseball, the Olympics and many other sports list both as performance enhancers, although football still isn’t testing for HGH.

So both HGH and testosterone can enhance performance. Do they work in similar ways?

The two function differently. Testosterone is a steroidal hormone that causes fairly rapid increases in lean muscle mass and strength. It’s a small molecule that’s primarily responsible for growth, and it influences and enhances male characteristics such as muscle and bone mass, aggression, and facial hair among other things. Testosterone is very potent when taken orally as a pill, applied topically as a gel, or injected with a syringe. The consequences of abuse are well documented to produce long-term effects in users. HGH, on the other hand, is a protein. HGH activates a receptor that tells cells that cause growth to turn on. It’s a large protein, as opposed to a small molecule. Additional HGH is introduced to the body via an injection… not pills or gels.

HGH introduces a slower onset of strength than testosterone might. HGH tells the body to use calories to build muscle and bone. If you were deficient, you would store them as fat. Studies have shown you recover from injury associated with athletics more quickly.

How do we detect use?

Testosterone use is very well documented. There are really good tests out there to detect it’s abuse.

You can measure levels and ratios of growth hormones in the body to detect HGH. But you’d have to catch somebody the day they take HGH, because it has a pretty quick half-life. Levels come down pretty quickly once you stop taking it. Mayo Clinic researchers are currently looking into better ways to detect it.

Both HGH and testosterone are available with a prescription. What are their appropriate uses?

Testosterone can help restore libido in older men, which can help with erectile dysfunction. It is commonly used in replacement therapy to alleviate metabolic disorders or deficiencies in people young or old.

HGH, on the other hand, is responsible for growth. It has a lot of uses in pediatrics and in people with growth-related disorders. For example, it can help cancer patients—especially children—regain growth after chemotherapy.

What about long-term affects of unnecessary use or abuse?

We don’t have data on what’s going to happen to someone that uses HGH who shouldn’t be using it in five years. With patients who take HGH for legitimate reasons, when they stop taking it they tend to see a little bit of a relapse, because their body doesn’t produce it, but HGH production does recover and normal function comes back.

Andre the Giant and Jaws from the 007 movies are good examples of the physical changes that can occur from too much growth hormone. Both had a tumor producing growth hormone that made them unusually tall, resulting in an enlarged jaw and dental problems. Too much HGH can lead to pre-diabetes symptoms, but we don’t know if that stops after HGH use ends. One question out there is, as you get older and take HGH unnecessarily, can it increase your cancer risk? HGH doesn’t make cancer happen, but it might make someone predisposed to cancer experience an accelerated rate of development.

With testosterone abuse, the body stops producing the levels of testosterone it needs naturally. Shrunken testicles are the classic long-term effect of abuse, but there’s a whole list of negative effects: shrunken muscle mass leading to hanging flesh on the body, an inability to produce enough testosterone later on, enlarged heart, kidney and liver problems, increased male characteristics in females and increased female characteristics for men, et cetera. If you use something like testosterone off-and-on, it can put you at a greater risk for injury during the low point of that cycle.

What’s the bottom line?

HGH and testosterone use encourages artificial enhancement of the body’s natural capabilities. Artificial enhancement is cheating, and sooner or later, the abuse of these drugs will catch up to them in one way or another.

Testosterone Replacement Therapy

Hypogonadism, or Low Testosterone

Hypogonadism, also known as low testosterone or “low T,” can lead to symptoms of decreased energy and libido, difficulty building lean muscle mass, moodiness, difficulty concentrating, and even loss of bone density. Men who have some or all of these symptoms and demonstrate low testosterone on a blood draw are candi­dates for testosterone replacement therapy (TRT).

There are many options for TRT, each of which has its benefits and disadvantages. The decision about which one is right for you will depend on your personal preferences and a discussion with your doctor. In some cases, different insurance companies may cover one option and not another, which may also be taken into consideration. If the desired effects are not achieved with your initial choice, a different option can be tried to see if it is a better fit for you, your health, and your life­style.
Evaluation of Low Testosterone

Regardless of the type of testosterone replacement therapy chosen, you will need to first be evaluated by your doctor and then monitored at regular intervals (usually every 3-6 months) to confirm good control of your hypo­gonadal symptoms, check levels of testosterone and perform other related bloodwork, and to ensure that there are no potentially dangerous side effects.

The evaluation and follow-up regimen usually consists of the following:

• Physical examination every 6 months, including digital rectal exam assess for signs of prostate enlargement and prostate cancer.
• Bloodwork every 3-6 months for testosterone levels and other hormones.
• Bloodwork every 6 months for lipids, hemoglobin and hematocrit, and PSA (prostate-specific antigen).

Is Testosterone Therapy Safe?

Millions of American men use a prescription testosterone gel or injection to restore normal levels of the manly hormone. The ongoing pharmaceutical marketing blitz promises that treating "low T" this way can make men feel more alert, energetic, mentally sharp, and sexually functional. However, legitimate safety concerns linger. For example, some older men on testosterone could face higher cardiac risks.

"Because of the marketing, men have been flooded with information about the potential benefit of fixing low testosterone, but not with the potential costs," says Dr. Carl Pallais, an endocrinologist and assistant professor of medicine at Harvard Medical School. "Men should be much more mindful of the possible long-term complications."

Signs of low testosterone

MIND

• Depression
• Reduced self-confidence
• Difficulty concentrating
• Disturbed sleep

BODY

• Declining muscle and bone mass
• Increased body fat
• Fatigue
• Swollen or tender breasts
• Flushing or hot flashes

SEXUAL FUNCTION

• Lower sex drive
• Fewer spontaneous erections
• Difficulty sustaining erections

The low-T boom

A loophole in FDA regulations allows pharmaceutical marketers to urge men to talk to their doctors if they have certain "possible signs" of testosterone deficiency. "Virtually everybody asks about this now because the direct-to-consumer marketing is so aggressive," says Dr. Michael O'Leary, a urologist at Harvard-affiliated Brigham and Women's Hospital. "Tons of men who would never have asked me about it before started to do so when they saw ads that say 'Do you feel tired?'"

Just being tired isn't enough to get a testosterone prescription. "General fatigue and malaise is pretty far down my list," Dr. O'Leary says. "But if they have significant symptoms, they'll need to have a lab test. In most men the testosterone level is normal."

If a man's testosterone looks below the normal range, there is a good chance he could end up on hormone supplements—often indefinitely. "There is a bit of a testosterone trap," Dr. Pallais says. "Men get started on testosterone replacement and they feel better, but then it's hard to come off of it. On treatment, the body stops making testosterone. Men can often feel a big difference when they stop therapy because their body's testosterone production has not yet recovered."

This wouldn't matter so much if we were sure that long-term hormone therapy is safe, but some experts worry that low-T therapy is exposing men to small risks that could add up to harm over time.

What are the risks?

A relatively small number of men experience immediate side effects of testosterone supplementation, such as acne, disturbed breathing while sleeping, breast swelling or tenderness, or swelling in the ankles. Doctors also watch out for high red blood cell counts, which could increase the risk of clotting.

The evidence for long-term risks is mixed. Some studies have found that men on testosterone have fewer cardiovascular problems, like heart attacks, strokes, and deaths from heart disease. Other studies have found a higher cardiac risk. For example, in 2010, researchers halted the Testosterone in Older Men study when early results showed that men on hormone treatments had noticeably more heart problems. "In older men, theoretical cardiac side effects become a little more immediate," Dr. Pallais says.

Some physicians also have a lingering concern that testosterone therapy could stimulate the growth of prostate cancer cells. As with the hypothetical cardiac risks, the evidence is mixed. But because prostate cancer is so common, doctors tend to be leery of prescribing testosterone to men who may be at risk.

"Like any treatment, there is risk," Dr. O'Leary says. "I would not give it to a man who is being treated for active prostate cancer, but it's pretty safe under careful supervision for those who need it."

For the time being, the long-term risks of testosterone therapy are "known unknowns." It offers men who feel lousy a chance to feel better, but that quick fix could distract attention from unknown long-term hazards. "I can't tell you for certain that this raises the risk of heart problems and prostate cancer, or that it doesn't," Dr. Pallais says. "We need a large study with multiple thousands of people followed for many years to figure it out."

So, keep risks in mind when considering testosterone therapy. "I frequently discourage it, particularly if the man has borderline levels," Dr. Pallais says.

Take a cautious approach

A large, definitive trial for hormone treatment of men is still to come. Until then, here is how to take a cautious approach to testosterone therapy.

Take stock of your health first

Have you considered other reasons why you may be experiencing fatigue, low sex drive, and other symptoms attributable to low testosterone? For example, do you eat a balanced, nutritious diet? Do you exercise regularly? Do you sleep well? Address these factors before turning to hormone therapy.

If your sex life is not what it used to be, have you ruled out relationship or psychological issues that could be contributing?

If erectile dysfunction has caused you to suspect "low T" as the culprit, consider that cardiovascular disease can also cause erectile dysfunction.
Get an accurate assessment

Inaccurate or misinterpreted test results can either falsely diagnose or miss a case of testosterone deficiency. Your testosterone level should be measured between 7 am and 10 am, when it's at its peak. Confirm a low reading with a second test on a different day. It may require multiple measurements and careful interpretation to establish bioavailable testosterone, or the amount of the hormone that is able to have effects on the body. Consider getting a second opinion from an endocrinologist.

After starting therapy, follow-up with your physician periodically to have testosterone checks and other lab tests to make sure the therapy is not causing any problems with your prostate or blood chemistry.

Be mindful of unknown risks

Approach testosterone therapy with caution if you are at high risk for prostate cancer; have severe urinary symptoms from prostate enlargement; or have diagnosed heart disease, a previous heart attack, or multiple risk factors for heart problems.

Ask your doctor to explain the various side effects for the different
formulations of testosterone, such as gels, patches, and injections. Know what to look for if something goes wrong.

Have realistic expectations

Testosterone therapy is not a fountain of youth. There is no proof that it will restore you to the level of physical fitness or sexual function of your youth, make you live longer, prevent heart disease or prostate cancer, or improve your memory or mental sharpness. Do not seek therapy with these expectations in mind.

If erectile function has been a problem, testosterone therapy might not fix it. In fact, it might increase your sex drive but not allow you to act on it. You may also need medication or other therapy for difficulty getting or maintaining erections.

TRT Update, 9 Week Blood Test

They call is "cruising" for a reason - I've just been cruising along, doing my test injections 1x per week and the hCG 2x. My initial prescription was for 10 weeks; at 9 weeks I had a Doctor consult scheduled and a blood test taken. Let's do the blood first, since that's probably what you're most interested in. These were my before-therapy levels:

Test	Result	Reference
Serum Testosterone	239 ng/dL	348 - 1197
Free Testosterone	8.0 pg/mL	6.8 - 21.5

And after 9 weeks of therapy (that would be 9 testosterone injections and 18 hCG injections):

Test	Result	Reference
Serum Testosterone	1,128 ng/dL	348 - 1197
Free Testosterone	29.4 pg/mL	6.8 - 21.5

So you can see that's a significant difference from my start numbers.

Serum Testosterone increased 889
Free Testosterone increased 21.4

My weight went from 184 to 196. They have an impedance body tester for body fat, not the most accurate I know, which showed me going from 14.9 to 13.7 percent.

I gotten stronger in bench (from 180x10 first set to 225x7), and the elbow and shoulder discomfort I had is mostly gone now. Unfortunately my back still bothers me, so I haven't been pushing on the squats and deadlifts. I did go from 275x6 on deadlift to 310x6, but that not really going all out.

So physically, there's been a very noticeable change. The more esoteric "mental" benefits have yet to manifest.

I still don't sleep well and frequently suffer from insomnia
No burst of mental clarity or increased motivation or focus
My energy levels do seem a bit higher during my workouts, but not increased overall.

The doctor didn't really have much to say when I pointed this out. She suggested a sleep aid supplement, which I declined.

I'm pretty happy as far as the gains go though, and I've decided to stick with it. So I continued the prescription with only one alteration, that being I decided (after consulting with the doc) to inject 2x a week, .5ml each time (for the same 1ml a week). I'd read this can provide more even test levels, plus it makes the shots a bit quicker and easier.

I'm still doing the shots myself using a 5/8 inch 28g needle in alternating quads on Mondays and Thursdays. No issues there. And the hCG in the stomach on Sundays and Wednesdays.

I did discover something interesting. With insurance, I was paying $78 a month for the testosterone cypionate and hCG, plus an additional $75 for the clinic fee, for a total $158 a month. So three months comes in at $474. If I use insurance, I can ONLY fill my prescription 1 month at a time.

If I "bulk" order from the clinics preferred prescription provider, I can get 3 months of testosterone cypionate and hCG for $425, a savings of about $50. So there you go....

Testosterone Repalcement Therapy, 5 Week Update

I've been meaning to write an update for a week and finally carved the time out today to do it. Yesterday was my sixth shot, marking the end of the fifth week since starting TRT. A good as time as any to give a status update, I suppose.

Energy-wise, I don't feel much different. Still tired, still sleep fitfully for about 6 hours a night. There's been no coalescing of focus, no sharpening of my mental acuity. I might  feel a bit more chipper, but I felt chipper for the most part to begin with. I wasn't depressed, but I still don't like my (admittedly well paying and fairly easy but completely unfulfilling) job.

Maybe a slight change on the sexual side of things. I wasn't having issues before, so no change there, although I have noticed a quality increase. By that I mean where I was maybe hitting an 8 or 9 on the "hardness" scale, I'm now hitting 10. Definitely a noticeable difference, accompanied by a bit more sensitivity as well. Maybe some other TRT users end up running around like randy teenagers, but not me. I'd say my level of desire is about the same as before.

I've gained some weight over the last 5 week, from 188 to 195, no change in waist size, but definitely more muscle. With this has come a cooresponding increase in strength. I don't feel a noticeable energy surge, but the weights float a bit easier, and I'm making gains again after a couple of years fighting to stay at the same place. Very nice to see a bit of muscle being added.

This relates to the above and is undoubtedly the source of my weight gain, but I've been much more hungry since starting the testosterone. Like craving food hungry, sitting down eating huge meals hungry. I'm definitely eating more (hence the weight gain) but it seems to be going to building muscle, not fat. Carb craving is a big part of this hunger, so I find myself eating stuff I'd put aside years ago: chips, candy, peanut butter and jelly sandwiches, pretzels.... I try to limit carbs and was doing so pretty successfully, but these new cravings have me stuffing them down. I need to clamp down a bit on that.

Anyone who's done a steroid or a prohormone is probably familiar with back pumps. Iv'e been gettingthose at a low level for a couple of weeks, to the point where it's difficult for me to run now. I've taken to jum[ping rope for my cardio. Running just cause my back to tighten up too much and is too painful. This si new and definitely related to the testosterone supplementation. I was running fine before, two miles three times a week. So the is for sure a TRT thing.

When it comes to going the bathroom, I've noticed the flow isn't as strong. My PSA levels were fine before hand. I need to do a bit of research on this. I'm not having and problems going, but still.... Related is my (still) waking up at  night to go to the bathroom. I generally wake up once, and occasionally twice. In the past, such nocturnal awakening where sometimes (50/50) accompanied by an erection. Now, every time, I've got to wait for the hydraulics to subside. Really, like every time. Annoying.

Overall, I'm happy with my progress. I especially like getting stronger and putting on some muscle. I don't like the back pumps and night time need-to-pee erections. My first blood test for levels comes at 12 weeks. I intend to continue with the testosterone replacement at least until that point and see how things are.

EDIT: I wrote this post 2 days ago, but didn't have a chance to proof and publish until now. I just finished my Wednesday workout and put up 255 on the bench. Not a lot to some folks, but, due to various shoulder and elbow issues (including elbow surgery a few years back), that's most I've done since I was in my 30s. I'm pretty pleased with that, and after only 5 weeks too!

Testosterone Replacement Therapy: is it Right for Me?

A buddy of mine at work has been singing the praises of his Testosterone Replacement Therapy (TRT) for some time now. At age 50, he’s few years older than my own 47. Like me, he’s been consistent with exercise for most of his adult life (although not as consistent as I’ve been).

Physically, we’re quite different. He’s about 5’9” and built like Gimili the dwarf; thick muscular neck, shoulders and chest with a wide, squat barrel-like build, like a power lifter or strong man. In contrast, I’m 6 feet tall, muscular, but much slimmer.  When I graduated college 25 years ago, I weighted 155. He weighed more than that as a freshman in high school!

I don’t see him every day – he works at a different location – but I ran into him after not seeing him for a couple of months. The thick upper body was still there, but so was a now-noticeable waist. He wasn’t a barrel anymore and was developing a definite v-taper. I asked if he’d lost some weight and he said he was down about 15-20 pounds. He was back in the gym more regularly, had changed his diet (mainly cutting out bread and pasta), and had started Testosterone Replacement Therapy.

And that was what he mostly talked about. How much more energy he had, how much better he was sleeping, how his focus had increased, how much more motivation he had. He mentioned (ahem) increased relations with his long-time girlfriend. He was getting stronger in the gym again after years of no gains. And he credited it all to TRT.

He gave me a few numbers: His blood test has shown his free testosterone to be in the mid 200s, which he said was almost 100 below the accepted bottom of normal range of 348. (I’ve since learned the range of normal for free testosterone is pretty wide, from about 350 – 1100, but I’ll talk more about in another post). Based on his blood test, the doctor had prescribed once weekly shots of 100mg of testosterone cypionate. After 30 days, his free testosterone had almost tripled to the mid 700s.

So he’s feeling pretty good. And he’s looking pretty good too.

I was pretty interested in all this. I’ve been working out with weights regularly for over 30 years, having first gripped the bar at age 15 after reading too many Conan comic books. With few exceptions (vacations, moving, injuries) I hadn’t missed more than a week or two in the gym in all that time.

I was never big though, never bulky. Like most inexperienced lifters, it took me a long time to figure out what worked best for me. I did way too much for way too long, and I’ve got the joint pain and past injuries (partially torn triceps tendon, disc ruptures, muscle strains, bone spurs requiring elbow surgery) to show for it. I never did any chemical augmentation, and my natural weight seemed to top out around 185-190 with around 15% body fat. That’s what I weigh now and what I’ve weighed since I was around 30 years old.

A few years ago I sensed my impending decrepitude and went on a hardcore Madcow 5x5. I managed to gain a few pounds and my lifts went up. At 44, I competed in a power lifting meet, lifting raw, and totaled an even 1,000 pounds in the 181 weight class (I cut about 8 pounds for weigh in the day before, and showed up to the meet just over 187). My squats and dead lift were pretty much on par with where they were in my low 30s; my bench was down (and will probably remain so) due to the elbow surgery and inability to go as heavier as I'd like. Not long after the meet, I hit a personal best dead lift of 435.

I was feeling pretty good about my progress, and seeing gains after a long period of stagnation motivated me. It motivated me right to a severely ruptured disc. It was my third warm-up set where I pull 305 for 3 or 4 on my way up to a working set of 405+. The weights felt heavy that day, but, ignoring the wisdom of my years (or rather not having any despite my years), I saddled up, pulled two, and on the third felt something I can only describe as a cork going off in my lower back.

My right leg went numb. Well, a weird mixture of numb and painful tingling, like when you hit your funny bone. That burning-numb feeling… I knew it was a bad one.

Here’s what they do most of the time when you have a ruptured disc: nothing. Unless you can’t control your bowels or bladder, which would indicate a level of nerve compression that could result in permanent damage, in which case they do surgery. Otherwise, you wait. If it gets better over time, even a tiny bit, you keep waiting. If, after about 3 months (so the doc said) there’s no improvement at all, then it MIGHT be time to start looking at a surgical solution.

Fortunately, I did get better over time. It took a few months for all the numbness in my leg to go away and for it to return to full strength. I was still in the gym, but staying away from exercises that put stress on my back. I was doing light weight for most things, and using slow reps to maximize time under tension. It seemed to work for keeping my mass, in that my weight changed only a little (dropping back to around 185) and my appearance stayed pretty much the same.

I’ll shorten up this whole boring story. It was almost a year before I felt comfortable trying squats, dead lifts and standing military again. And when I started back, I went very slowly and very carefully. Even now, more than three years after the injury, I’m still cautious when it comes to squats and dead lifts. Gone are the days of pulling 405 for a triple, and the most I’ve squatted since was 275 for a set of 4… and that made me very nervous. I mainly stick to front squats now, and changed my dead lifts to sumo style to minimize stress on my lower back.

So the point of the wall of text above was to paint a picture of an individual to whom age was starting to grip and who didn’t want to go down without a fight. Was testosterone replacement therapy an alternative treatment that might help?

I had many of the same symptoms my buddy had complained of: fatigue, poor sleep, a feeling of malaise, dry skin (especially my lips), and a few others straight off the Do You Have Low T pamphlet.

Maybe aging didn't have to be a slow descent into infirmity. Maybe it could be a period of decent vitality followed by a sudden decline instead of a long drawn-out one.

I got the name of the clinic from him and decided to find out what it was all about.