Testosterone Replacement Therapy

Steven Paletsky, M.D. Florida Specialists in Urology

No Speaker Disclosures

Average Testosterone Level

AGE Average Testosterone Range Level under 25 692 376 - 1008 25-29 669 257 -1081 30-34 621 233 -1009 35 -39 597 219 - 975 40 - 44 597 201 - 993 45 - 49 546 190 - 972 50 -54 544 170 - 918 55 - 59 552 160 - 900

Where should we aim? 500 - 800

Symptoms of Hypogonadism

Diminished Libido Erectile dysfunction Increased fatigue Difficulty in achieving an orgasm Decreased intensity of the orgasm Diminished sexual penile sensation Diminished energy, sense of vitality, or sense of well-being Depressed mood Diminished muscle mass & strength Diminished bone density Anemia Impaired cognition (?)

Testosterone Replacement

Testosterone Cost

Replacement therapy

Excretion HALF - LIFE Testosterone Cypionate Urine 90%, Feces 6%, 8 days Testosterone Transdermal Urine 90%, Feces 6% 10-100 min

Benefits of Testosterone

Reduce fat & Increase muscle

Improve your concentration

Maintain sleep & feel more rested

Maintain bone density/strength

Increase strength & athletic performance

Improve insulin sensitivity

Improve mood

Improve erectile function

Heighten your motivation

Increase sense of well-being

Testosterone

Circadian rhythm - best taken between 7 to 10 AM

Draw fasting or with little food

Variation blunted with age ( can draw til 2 PM)

When to draw later in the day?

Replacement

Can/Should you replace as a primary care physician? YES

How should you start? Baseline Free & Total testosterone CBC, CMP, PSA, DRE

Initial dosage? Testosterone cypionate 200mg/cc, 1/2cc IM, q wk (Receiving 100mg)

Follow-up? Free & Total testosterone after 3rd cycle (4 days post injection) Estradiol level? (breast tenderness?)

Should you treat if blood levels normal???

End point in treatment? Normal levels

When to stop? No benefit, cost, side effects (acne, aggression, etc)

Monitoring Replacement Therapy

Interesting Facts About Testosterone

High levels in females is an indicator of Polycystic Ovarian Syndrome

Testosterone increases level of Growth Hormone

Low T causes causes insomnia, sleep disturbances. Worsens sleep apnea

DHEA, Zn increases T

T converted to DHT harms hair follicles, causing baldness

T decreases fat mass, increases muscle mass, causes polycythemia

Aromatase

Involved in production of Estrogen from Testosterone

Location - Adrenal, Ovaries, Testicles, Fat, Brain

Converts Androstenedione and Testosterone to Estrogens

Estrogens can not convert to Testosterone

Increase FSH & LH hormone, therefore increase Testosterone

Anastrozole - Aromatase inhibitor Side effects - Hot flashes, decr. sex drive, osteoporosis, myalgias

Clomid - an estrogen blocker, may incr. sperm count

SHBG - Sex Hormone Binding Globulin

Glycoprotein that binds to androgens and estrogens

High levels indicate less total T

Increase levels seen in Liver dz and Hyperthyroidism

Produced in the Liver

Level decreases high levels of Insulin, GH, Prolactin, Androgens

Adverse effectsCardiovascular - Evidence suggests neutral or beneficial effect Lipid levels - evidence suggests no change Erythrocytosis - 3-18% with transdermal 44% with injections Fluid retention - rarely seen Prostate enlargement - slow progression Prostate cancer - Probably not the cause, increases growth rate Hepatotoxicity - seen with oral replacement Sleep apnea - infrequent Gynecomastia - rare, reversible Skin reactions - 66% patch, 5% gels, rare with injections Acne - rare Testicular atrophy - can occur, especially in young men, reversible Infertility - usually reversible

Contraindications

Breast cancer

Polycythemia?

Prostate cancer

Elevated PSA?

Desired fertility

Severe lower urinary tract symptoms

Uncontrolled CHF

Untreated obstructive sleep apnea

The Future

Questions?