Announcer: You are listening to highlights from a low testosterone educational seminar led by Urology San Antonio physician, Dr. LeRoy A. Jones. If you have questions about the material presented or would like an appointment to discuss you specific medical situation, you can reach Urology San Antonio at (210) 614-4544, or visit us online at urologysanantonio.com.
Dr. Jones: I’m Dr. Jones with Urology San Antonio. The name of this talk is Low Testosterone. You can see what’s written here, “Testing Testosterone: If you haven’t been feeling quite yourself in the boardroom or the bedroom, you want to talk to your doctor about a condition called male menopause.” That’s probably not true; it’s probably more of a media term. I think everyone knows what menopause is with regard to women. So the media like to latch on to the male aspect of that.
Aging. We will see it as guys get older ? maybe 15 percent of guys age 50 will have low testosterone, and it goes up about 10 percent every year. It’s something to look for, even in guys who are healthy older men, but if they do notice a lower sex drive, maybe some problems with erections or changes in their energy or mood, then they may be suffering from low testosterone. Again, with women, there is a clear age relationship, but with guys it’s not so clear. A lot of my patients… I take care of guys in their 20s, 30s, 40s that have low testosterone who are being treated in a variety of different way. So it’s not all about aging like you may think.
So low testosterone, the medial term is hypogonadism. Testosterone is a hormone. And a hormone basically is a signal to the rest of the body. It’s produced primarily in the testicles. That’s where most of it is. And it’s measured by a blood test. It’s very simple: a morning blood test, fasting. And [from that] we’re able to get a good idea of where the individual where will be. Why the morning? Well, toward the end of the day, it actually falls off. That’s probably why many of us get tired toward the end of the day; the testosterone level will fall off. But that’s normal. You have that peak in the morning, then it kind of falls off.
When we look at low testosterone, there are a couple of different ways to define it. One is primary, meaning the testicles don’t work. They are still getting the signal. So the signal comes from the brain to drive the testicles to make testosterone. So either the testicles don’t work or the signal is not getting there. And you may have a combination of the two. Primary testicular failure is more common. The testicles, they get the signals but they are not responding to the signal.
When you look at the different causes, there are a lot of different things: aging, medicines, disease states – all of that stuff can affect the production of testosterone. And then there are some other unusual things. But even obesity, in and of itself, can lower testosterone.
Testosterone is broken down into different forms: free and that which is bound to a bunch of different hormones. So that which is bound to hormones is not what we call bioavailable; it can’t really work. But the free testosterone is free to go around and send its signal to the cells.
The normal testosterone range is around 300 to 800, more or less. So if a guy comes in and his testosterone level is 280, he’s probably not going to have some of these effects. A lot of it depends on his age because what’s normal for a 20-year-old is going to be different for a 60-year-old. The normal levels are different. So we expect the normal testosterone level as guys get older to be different from somebody who is younger.
Some of the [symptoms] you can see with low testosterone is increase in body fat, decrease in muscle mass. Some guys will complain that they are loosing their strength. The golfers particularly will say, “I can’t hit the ball as far.” So maybe they’ve lost some muscle mass. Probably one of the most important things, I think, is osteoporosis or thinning of the bones. There are some guys running around with testosterone that’s pretty low, say 100. Even if they have no other symptoms (libido and their mood is ok), they should probably still be treated because they are going to be at risk of osteoporosis. Decline in libido. (Libido is sex drive.) And then also erectile function. And then well-being, which is probably mood. In a lot guys, once they start testosterone, and you ask their wives, “Is he happier?” There is a big difference. “Yes, he’s happier. He’s not as grumpy.” So certainly mood can be affect by testosterone.
So how do you diagnose it? These are some of the things: mood changes, fatigue, loss of muscle mass, low sperm count (you’ll see that mostly in the younger population). These are some of the things that patients can suffer from. There are also some questionnaires out there that have been developed looking at if the patient has symptoms. This one is from St. Louis University: “If they have a decrease in libido? Sex drive? Lack of energy? Less strength or endurance? Have they lost some height over time? Decrease in the enjoyment of life?” And again, that’s that happiness and are you sad or grumpy? So you can see, there are a lot of things on here related to mood on there. And so the mood really is a key determinate. A lot of guys, once they start testosterone treatment, they feel better. They feel better about themselves. Their mood is better. They interact with others better. And so the mood is really a key player. “Are the erections less strong? Recent deterioration in the ability to pay sports? Falling asleep after dinner? Deterioration in work performance? Concentration?” So these are all some of the symptoms that guys should probably ask themselves [about] if they think that they have low testosterone.
So you can kind of see here [on the slide] the serum total testosterone. This includes the free plus the bound. And as I said, it’s the morning levels so that morning level is 300. If it’s less than that, the patient has low testosterone. But some labs may report their normal lower end at 240… so somewhere around there. And then also, there are guys that come in, maybe it’s a 45-year-old guy whose testosterone is 325, which is normal, but he has all of these symptoms. What he and I may elect to do is to treat him for six months and see what happens. We’ll see if the symptoms go away. So even through he’s normal, we’re still going to treat him and see if his symptoms get better. And if they do, then he may elect to stay on it. And if they don’t, maybe there is something else. If he’s not happy and his mood is not good, then maybe he’s suffering from some depression that he hasn’t recognized yet. If their testosterone is low and they do elect to be treated, their body isn’t going to start making it. That’s another question people ask, “How long do I need to stay on this?” Well, if the body doesn’t make it, it’s not going to start making it. And so, usually patients will end up staying on it.
What are some of the concerns prior to giving somebody testosterone? Probably the big one that everyone hears about is prostate cancer. Maybe the one take home message here, if you hear anything, is that testosterone does not cause prostate cancer. It doesn’t cause it. But if someone has it, it may make it show up sooner than it was meant to show it. But it does not cause it. It not going to take normal prostate cells and turn them into cancer. But all guys need to be screened for it. So even if they are young guys, even if they are 30-years-old and they are done with their kids and they want to be on testosterone, they need to be checked for prostate cancer.
Testosterone may cause some hypertrophy of the muscle in the neck that may worsen sleep apnea, and sometimes that’s an issue for patients. Testosterone may cause the prostate to grow. If it grows, the individual may have some problems urinating. These are some of the issues that we address when talking to patients.
How do we treat it? These are some of the different treatments. Pills. There are no pills in the United States. It doesn’t exist. The concern is in the FDA that it causes liver cancer so there are no oral pills for testosterone. There is little pellet implants. There’s patches. There are patches that you can wear on your scrotum or nonscrotum application, but I don’t use too much of that because I think it causes some irritation to the skin, especially if it is hot.
Then there’s gels. We tend to use more gels than anything else. But some of that is dictated by insurance because the gels are expensive. [We use] 1% dosing. The patient will apply this. I recommend that patients, when they get out of the shower in the morning, put their gel on. They rub it in. It comes in a little dispenser that looks like lotion. You can rub it into the shoulder areas. And we figure out the dose that the patient needs to be on, how many pumps that they need to use. And we titrate them up to proper dose. And so the gels are what we tend to use.
And then if the gels don’t work, we’ll use intramuscular injections. When we have somebody on injections, the dose is usually 200 mg, usually every two weeks. It’s an intramuscular injection. We usually inject the patients. Some of the patients come to our office every two weeks. For some people, that’s not convenient so we’ll teach them or teach their partner how to give the intramuscular injections. The one thing about the injection therapy is that…with injection therapy you can image that if you are giving it every two weeks… if the normal range is that window between 300 and 800, well if you give somebody an injection, they may go up to 2,000, and then it slowly tapers down over the next couple of weeks. So that’s where you get out of the normal, what we call the normal physiologic range. And that’s where you may see some more side effects where it may alter the cholesterol or may alter the blood count. Now, there are a lot guys who are on injection therapy, but the side effect profile is higher if the patient is on injection therapy verses the gel. When somebody is on a gel, they stay within that window. They don’t have those severe fluctuations. So the treatment is more physiologic; it’s more natural. That’s why we tend to use the gels; there’s less fluctuation.
These are just some cost issues. You can see if you are paying… these are from a number of years ago, and obviously everything has gone up since then, but this will give you an idea of the relationships between the injections, which are cheap, verses the gels. The gels are very expensive outside of insurance. They are $220 or so a month, maybe $240.
When somebody wants to be on testosterone therapy, what I do is I follow the patients every three months. So they come in, they get their prostate checked and a blood test. I’ll do that for a year. And if everything is fine, then every sixth months. And then they can go back to a regular prostate check once a year. I’m pretty rigid about that because we don’t want to miss anything. The patients understand. They come and they get their blood test and they get their prostate checked. So that’s the kind of relationship or contract we have with the patient. But again remember, the testosterone doesn’t cause prostate cancer; it doesn’t cause it.
Testosterone is not an exact science by any means. There’s certainly a lot of art to it, sort of the art of medicine. And obviously, there are going to be some personal opinions of the physician that’s treating the individual. And there’s certainly lots of discussion about it, lots of controversy about it. Overall, I think it’s a reasonable hormone for guys to be treated. It’s not the end-all for all patients, but it may be a component of some of the symptoms that they are suffering.