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.

A Look at Testosterone Replacement Therapy (TRT)

Testosterone replacement therapy (TRT) has surged in popularity over the past decade. Millions of men have turned to TRT to restore hormone levels in hopes of refueling energy and reigniting their sex drive.

Yet TRT remains controversial because of its uncertain benefits and potential health risks. Safety concerns were raised when studies showed a possible association between TRT and an increased risk of cardiovascular disease.

Dr. Frances Hayes, a reproductive endocrinologist with Harvard-affiliated Massachusetts General Hospital, points out that some of these studies had limitations.

"For instance, in one study, TRT doses were much higher than what would usually be prescribed, and the subjects tended to be more frail, with other health problems," she says. "Other studies showed no evidence of increased risk."

The Latest Findings

Recent research has supported this position. 

A study reported at the 2015 American Heart Association Scientific Sessions involved 1,472 men ages 52 to 63 with low testosterone levels and no history of heart disease. Researchers found that healthy men who received TRT did not have a higher risk of heart attack, stroke, or death.

Furthermore, a study in the August 2015 Mayo Clinic Proceedings showed no link between TRT and blood clots in veins among 30,000 men. "Right now, the jury is still out about TRT's influence on cardiovascular disease," says Dr. Hayes.

TRT's relationship with other health issues is also mixed. For instance, TRT has previously been tied to a higher incidence of prostate cancer, but a study published in the December 2015 Journal of Urology found that exposure to TRT over a five-year period was not linked to a greater risk of aggressive prostate cancer.

The bottom line is that the long-term risks of TRT are still unknown, as many of these studies have limited follow-ups. 

That does not mean you should avoid TRT. For a selected subgroup of men, the therapy can be a viable option.

Who is a candidate?

You need to have both low levels of testosterone--less than 300 nanograms per deciliter (ng/dL)--and symptoms to get a prescription for TRT. 

"It is possible to have low levels and not experience symptoms," says Dr. Hayes. "But if you do not have any of the key symptoms, especially fatigue and sexual dysfunction, which are the most common, it is not recommended you go on TRT given the current uncertainty with regard to long-term safety."

A simple blood test measures testosterone levels. Several tests are required, as levels can fluctuate daily and be influenced by medication and diet. 

"In 30% of cases where the first testosterone test is low, levels are normal when the test is repeated," says Dr. Hayes.

Even if your levels are low and you have several symptoms, TRT is not always the first course of action. "If you can identify the source for declining levels, often you can address that problem and increase low levels naturally," says Dr. Hayes.

For instance, the No. 1 contributor to falling levels is weight gain. "Weight has a bigger impact on testosterone levels than aging. As weight goes up, testosterone levels go down," she says. A five-point increase on the body mass index scale is equivalent to adding 10 years to your age in terms of testosterone levels.

"Your doctor should also review any other factors that might influence levels, like medication or medical conditions," says Dr. Hayes. In these instances, your doctor may treat the underlying condition or change your medication or dosage to one that would not affect testosterone levels.

Men also need to understand the limits of TRT, as many envision it as a type of fountain of youth. "Its impact is less than what many men would expect," says Dr. Hayes.

For example, two often-touted benefits of TRT are sexual health and vitality. A double-blind study in the Feb. 18, 2016 issue of The New England Journal of Medicine reviewed the effects of TRT on 790 men ages 65 and older. Those who received TRT for one year, versus those on placebo, saw improvements in sexual function, including activity, desire, and erectile function. 

However, the group experienced only a slight improvement in mood and saw no changes in walking speed, which was used to measure TRT's effect on vitality.

Using TRT

TRT is often given by either gel application or injection. With a gel, you spread the daily dose over both upper arms, shoulders, or thighs. Injections are typically given into the buttocks once every two weeks.

Each method has its advantages. With gels, there is less variability in levels of testosterone. 

With injections, testosterone levels can rise to high levels for a few days after the injection and then slowly come down. This can cause a roller-coaster effect, where mood and energy levels spike before trailing off.

Most men feel improvement in symptoms within four to six weeks, although changes like increases in muscle mass may take from three to six months.

TRT may not always need to be taken for life. 

"If the issue that caused your testosterone levels to drop in the first place resolves, you should have a trial off treatment and be re-evaluated by your doctor," says Dr. Hayes

End of the First Week

I had my first testosterone shot Monday afternoon, and went through a normal week. My regular work schedule is 6:15am - 2:15pm, which gets me home about 3:15. My 14 year-old son gets home from school around 3:30. We have a home gym, a power cage we built ourselves along with an olympic bar and bumper plates and other weights up to 315 pounds. We lift together 3x per week, a reverse pyramid workout on Mondays, Wednesdays and Fridays.

I try to hit the hay around 9ish and read a bit, with lights out before 10. That typically gives me 6-7 hours of sleep a night, depending on how quickly I fall asleep, how many times I wake up to take a leak, and how (or if) I'm able to fall back asleep again.

Boring stuff, I know, but I'm telling you all this so you'll have an idea of my schedule. Maybe you'll see some aspects of your own in it....

As I mentioned at the end of my first shot post, I didn't feel any different in the days following the injection. No increased energy or coalescing of mental focus, still sleeping fitfully, no sudden reversal of the lethargy I'd been in the grip of for some time.

However...

That first weekend following the shot, I was was hungry. And I don't mean a bit peckish, I mean hungry. Like can't get full hungry. So I ate. A lot. Generally, I kept it healthy (I tend to eat fairly healthy most of the time anyway). But I powered through a more than normal amount of food, no doubt.

I don't generally pay much attention to my weight. I mentioned in an earlier post that I've been within a pound or two of 185 for a long time. But my hunger and the resulting feeding frenzy over the weekend made me curious enough to step on the scale, where I was greeted by a surprise: 189.

So it looked as though I'd gained a few pounds. Maybe I'd been eating more all week? I hadn't been bothered by hunger until that weekend, but it's a possibility.

So end of first week, not feeling any different, but up around 4 pounds. Make of that what you will.