Testosterone Replacement Therapy
Hi, thank you for coming back for the latest edition of Beyond Primary Care’s blog- testosterone replacement therapy. In Beyond Primary Care blogs we highlight healthcare news, advice for medical conditions, and how membership for care works! Beyond Primary Care is an insurance free, membership based family medicine clinic. Beyond Primary Care is the highest rated Direct Primary Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne counties giving families and employers peace of mind about healthcare costs by providing affordable and accessible primary care services.
In this blog post, we wanted to give our patients and prospective patients updates on safe and effective testosterone replacement therapy.
What is Testosterone
Testosterone is a hormone produced by the gonads in men. However, testosterone isn't just a hormone for men. Women make much smaller amounts of testosterone than men – about 1/10th as much. A smaller quantity is also produced by the adrenal glands which sit atop the kidneys in both sexes. Testosterone production increases during puberty and typically decreases with age.
Low testosterone is common, with 40% of men over the age 45 living with low testosterone and its symptoms. In fact, a man’s testosterone coincides with the presence of conjuring health conditions (eg- Type 2 Diabetes, Heart Disease, Metabolic Syndrome) reaching as high as 80%. When testosterone gets too low, known as “low T” or “hypogonadism,” this imbalance can have a significant impact on your health and your life with unpleasant symptoms, such as:
Decrease in Body Hair
Fatigue
Infertility
Low Sex Drive
Depression and Irritability
Role of Testosterone in Males
Testosterone is an androgen, meaning that it stimulates the development of male characteristics. It initiates the development of the male internal and external reproductive organs and is essential for the production of sperm in adult life. In both sexes, testosterone affects bone density, muscle mass, and fat storage
Testing for Testosterone
Testosterone is measured through simple blood testing where the serum testosterone is measured. The test is typically performed in the morning, when the testosterone levels are the highest. A total testosterone lab tests measures both ‘free’ testosterone and the amount of testosterone bound to blood proteins, mainly albumin and sex-hormone binding globulin (SHGB). Normal testosterone levels are between 300 to 1,000 ng/dL
Unbound testosterone, also called free testosterone, accounts for a much lower amount in the body, only about 1-2% of testosterone. Normal free testosterone levels are between 4.5 to 25 ng/dL.
Testosterone Replacement Therapy
Testosterone replacement therapy can help reinvigorate your sex life, boost your energy levels, and improve your mood. Once a testosterone deficiency has been identified, you could be a candidate for testosterone replacement therapy. Testosterone replacement therapy optimizes your hormone levels with the goal of improving your symptoms and quality of life. This article reviews a few select modes of testosterone replacement therapy.
It is reasonable to start seeing results 3-6 months after starting testosterone replacement therapy. We always advise to pick one aspect / symptom of why testosterone replacement therapy is started and track that so that adjustments to your treatment plan may be made as needed.
Oral Administration
Currently, oral testosterone replacement therapies are not available in the United States. Oral administration of testosterone has been unsuccessful in increasing tester one levels as the oral medications are extensively metabolized by the liver before any bioavailability may occur.
Testosterone Cypionate
Testosterone Cypionate is a schedule-III controlled substance in the United States, meaning individuals can’t legally obtain it without a prescription and licensed physician guiding individuals in treating the low testosterone. Testosterone Cypionate is given via injection into the muscle (gluteus, thigh) which means it can be dispersed slowly within your body over a long period of time and is very bioavailable to the tissues. Testosterone Cypionate injection amount and frequency varies depending not treatment plan between you and your physician.
Testosterone Gel
Testosterone gel (Brand: AndroGel) is also a schedule-III controlled substance in the United States. Testosterone gel is applied daily to the skin of large muscle groups (eg- chest, shoulders, abdomen). Advantages include less fluctuation in testosterone levels because of the daily application and avoidance of needles. Disadvantages include a slightly increased cost compared to Testosterone Cypionate and potential for skin irritation.
Testosterone Patches
Testosterone patches (brand: Androderm) appear and feel like nicotine patches for those trying to quit smoking. Like trying on a new bandaid, you apply a new one every night to your skin before bed. Again, advantages include less fluctuation in testosterone levels because of daily application and another good option for those preferring non-invasive (read: no needles) treatment. Unfortunately, this form of testosterone treatment is less used because insurance companies will often deny this in favor of more affordable treatments and the cash price is significantly more compared to other testosterone therapies.
Compound Prescriptions
For many, low testosterone is more than a low sex drive and even using prescription medications sometimes don’t work or the side effects are too frustrating. At Beyond Primary Care, we work with several compounding pharmacies who offer a number of prescription testosterone prescriptions, both on-label and off-label solutions, gels, and pills customized to the unique needs of the patients.
The most common testosterone replacement therapy preparations are include Clomiphene Citrate and Enclomiphene Citrate.
Clomiphene Citrate
Clomiphene Citrate (brand: Clomid) is a non-steroidal selective estrogen receptor modulator (SERM) medication, that occupies estrogen receptors in the brain. This medication effectively uses a ‘back-door’ mechanism to increase testosterone levels because the treatment causes a cascade hormone reaction that ultimately results in the stimulation of endogenous testosterone production in males. This huge advantageous is that since Clomiphene Citrate increases men’s testosterone in a more ‘natural’ way, there is no drop off in the testes’ ability to make testosterone- and this medication could be continued indefinitely with periodic monitoring. Other advantages of this medication is that it comes in an oral form and its costs are more reasonable. The time it took for improvement in symptoms was typically three months.
Enclomiphene Citrate
Enclomiphene Citrate (brand: Androxal) is the isomer of Clomiphene Citrate- almost like a twin, but with slight differences. The medication works similarly as Clomiphene. However, a big advantage is studies have shown Emclomiphene to be superior to testosterone in preservation of semen parameters while remaining effective in increase testosterone levels. For men wishing to continue their chances of having a family while increasing their testosterone levels, Enclomiphene Citrate may be beneficial.
Safety with Testosterone Replacement Therapy
Beyond measuring the testosterone on a periodic basis, other blood tests may be required to maintain safety in treatment of low testosterone. A PSA (prostate-specific antigen) blood tests is used to monitor PSA concentration as testosterone therapy stimulates the growth and function of the prostate gland. A CBC (complete blood count) may also be measured to keep a baseline and trend the red blood cell counts (hematocrit), which may go up because of testosterone supplementation. A portion of the testosterone supplementation is converted to estrogen. Unchecked elevated estrogen levels may lead to male breast development (gynecomastia) or nipple tenderness. Lastly, testosterone supplementation may lead to increased low-density lipoprotein (LDL cholesterol) levels, so routinely checking lipid levels is important.
When Do You Stop Testosterone Replacement Therapy
There is no cure for low testosterone and testosterone replacement therapy is just that- a replacement for the period you take it. Meaning that, in most cases, in order for low levels of testosterone to be increased, it is dependent on a medication taken consistently throughout one’s life. The length of time your body needs to restart making its own testosterone (endogenous) does not have a definitive timeline. Reasons to stop using testosterone include worsening acne, enlarged prostate, polycythemia (too many red blood cells),
Thank you for reading
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