Treatment for low testosterone levels usually involves hormone replacement therapy. The method of delivery can be determined by preference, age and the duration of deficiency. Treatment for adults is aimed at maintaining secondary sex characteristics, improving energy, strength, mood, and feelings of well-being, and preventing bone degeneration. Testosterone replacement should in theory approximate the natural production of the hormone. The average male produces 4-7mg of testosterone per day in a circadian pattern, with maximal plasma levels attained in early morning and minimal levels in the evening.
The modes of delivery include transdermal, injection, and oral.
Transdermal delivery (through the skin) is used to administer therapeutic agents for hormone replacement. Transdermal replacement therapy with a testosterone patch is becoming the most common method of treatment for testosterone deficiency in adults. It establishes and maintains adequate serum levels without causing significant side effects in as many as 92% of men treated. A patch is worn, either on the scrotum or elsewhere on the body, and testosterone is released through the skin at controlled intervals. Patches, like Testoderm (scrotal) or Androderm (nonscrotal), contain natural testosterone and are typically worn for 12 or 24 hours and can be worn during exercise, bathing, and strenuous activity. It delivers about 4-6mg of testosterone daily and is applied to the shaved scrotum. Androderm is a very similar preparation which can be applied anywhere. Patches are applied each morning and result in a surge of hormone within a few hours of application.
The most common side effects associated with transdermal patch therapy include itching, discomfort, and irritation at the site of application. Some men may experience fluid retention, acne, and temporary gynecosmastia.
The results of a study showed that the application of a transdermal cream significantly increased free and total testosterone levels in men. As these testosterone levels persisted for up to 36 months in patients using a cream, the study shows that absorption continued, testosterone did not accumulate and levels remained stable. Creams typically come in 2, 5 and 10% concentrations or 10, 25 or 50mg/ml or gram. The cream dose for men is typically in the range of 25 to 50mg per day. Testosterone cream can also be used by women, but at a much lower dose, usually 1 – 2mg per day. A special caution for women: long term use of a cream has resulted in increased hair and hair darkening at the site of application.
Androgel is a transdermal gel that is applied once daily to the clean dry skin of the upper arms or abdomen. It delivers testosterone for 24 hours when used properly. The gel must be allowed to dry on the skin before dressing and must be applied at least 6 hours before showering or swimming. It cannot be applied to the genitals. Side effects may include adverse reaction at the site of application, acne, headache, and alopecia.
A recent study of hypogonadal men found that patients treated with Testim, a 1% testosterone topical gel marketed by Auxilium Pharmaceuticals, Inc., absorbed 30% more testosterone dose for dose than patients treated with AndroGel.
Intramuscular injection is used less frequently because it is associated with erratic testosterone levels. Levels that get too high and then drop too low before the next dose may cause fluctuating moods, energy levels, and libido.
Children and adolescents with low testosterone and delayed puberty may be treated with low doses of testosterone by this method to induce puberty. Adolescents may receive gradually increasing doses that last longer in the body, because, with age, there is less risk for affecting normal growth patterns.
Oral testosterone (methyltestosterone, Testred – pills) is prescribed sparingly, because it is associated with liver toxicity and liver tumors.
Testosterone and testosterone analogues have long been used in the athletic community for improving lean muscle tissue and strength. Although this action of testosterone was denied over the years, the scientific proof of the link between testosterone and muscle was shown in 1996. Since that time there has been a virtual explosion in the use of testosterone and testosterone analogues.
In individuals with normal levels of testosterone, the use of testosterone will result in a decrease and possible cessation in the body’s production of GnRH, LH and testosterone. After an individual stops or halts the use of testosterone, or other androgen, the body does not immediately resume the production of these hormones. A period of androgen induced hypogonadism, begins of an unknown duration and severity. This period is related and proportional to the type, dose and duration of the androgen(s) used during treatment. For the individual beginning testosterone treatment with normal levels the period after androgen cessation deserves important consideration.
While some research suggests that the hormonal axis will spontaneously return to normal shortly after cessation of testosterone administration, birth control studies utilizing testosterone have taken over 6 months for HPGA normalization. Testosterone therapy, once begun, may become a life-long commitment. In the individual who has mild or moderate benign prostatic hyperplasia or latent prostate cancer, androgen treatment may be potentially problematic.
Testosterone can help with the following
Sjogren's Syndrome
We hypothesize that androgen deficiency, which reportedly occurs in primary and secondary Sjögren’s syndrome (e.g., systemic lupus erythematosus, rheumatoid arthritis), is a critical etiologic factor in the pathogenesis of dry eye syndromes. We further hypothesize that androgen treatment to the ocular surface will promote both lacrimal and meibomian gland function and alleviate both “aqueous-deficient” and “evaporative” dry eye. Our results demonstrate that androgens regulate both lacrimal and meibomian gland function, and suggest that topical androgen administration may serve as a safe and effective therapy for the treatment of dry eye in Sjögren’s syndrome. [Annals of the New York Academy of Sciences 876:312-324 (1999)]
Low Sex Drive
Low testosterone levels are frequently the reason for diminished interest in sex, both in men and in women.
Male Gynecomastia
Gynecomastia is a common condition in athletes who use steroids or testosterone to build muscle. The condition is caused by the aromatization of testosterone into estrogens. Gynecomastia may be avoided through the use of dihydrotestosterone instead of other forms of testosterone. It can actually even be applied as a treatment for gynecomastia. A further advantage of dihydrotestosterone is that increased levels of the hormone are correlated to increased sex drive and increased sexual function.
Enlarged Prostate
Prostate gland growth and PSA levels were reduced or reversed in men whose LH levels were also lowered. Testosterone therapy reduces excess secretion of LH. [Int J Androl 2002 April; 25(2): pp. 119-25]
Increased Risk of Alzheimer's / Dementia
The popular image of this sex hormone is primarily as a muscle-building machismo-inducing substance that “pumps men up”, yet clinical research is uncovering important roles for testosterone in many other diverse areas of health and physiology, including the brain. New evidence suggests that testosterone may enhance memory function and protect against the development of Alzheimer’s disease.
Neuroscientists from Rockefeller University and Weill Medical College of Cornell University recently discovered that when neural cells from the brains of rats are exposed to testosterone, the cells don’t produce as much Amyloid beta-peptide (AB-peptide). The accumulation of AB-peptide can cause plaque deposits to form in the brain. These deposits are believed to play a major role in the development of Alzheimer’s disease.
Testosterone in addition appears to improve certain cognitive abilities in men, such as verbal and spatial memory function. Levels of bioavailable testosterone are especially important, researchers emphasized, because these levels decline most rapidly as men and women age.
Since high levels of testosterone have been linked with prostate cancer in men and endometriosis in women, however, they urged caution when using replacement therapy, carefully weighing the risks and benefits for each patient.
Increasing levels of adrenal hormones such as cortisol, which rise in response to stress and aging, may also play an important role in Alzheimer’s. High levels of these hormones can damage the hippocampus region in the brain, causing
learning impairment and memory loss. Testosterone, however, shows the potential to reverse some of this damage.
Increased Risk of Prostate Cancer
One of doctors’ greatest fears about testosterone therapy is that it may cause prostate cancer. But a study shows that it won’t increase a man’s risk of prostate cancer – even if he has precancerous prostate cells. The study sheds light on the risks of testosterone therapy, which is used in men with low testosterone levels to help restore a man’s sexual function, mood, memory, even aspects of his physique – muscle mass, strength, body fat, bone density.
These results indicate that testosterone therapy does not lead to prostate cancer and that men with a history of precancerous prostate cells may be able to safely take testosterone therapy. [Journal of Urology December 2003]
Preliminary research suggests that testosterone replacement therapy for men with low testosterone levels appears to have little effect on the prostate gland, contrary to some reports that this therapy may be harmful, according to a study in the November 15, 2006 issue of JAMA, a theme issue on men’s health.
Prostate Cancer
Men in the early stages of prostate cancer may find that therapy to reduce male hormone levels may be more harmful than beneficial, according to a National Cancer Institute study. Researchers found that men who had the therapy were over twice as likely to become impotent and five times as likely to experience hot flashes and breast swelling – versus men who did not choose this treatment.
Worse than the side effects, this suffering may be in vain since there is no evidence that androgen deprivation therapy (ADT) is effective when used alone. The goal of ADT is to lower or eliminate male hormones, which have been thought to promote tumor growth in the prostate. There are several ways to accomplish this, including removing the testicles or having patients take the female hormone estrogen.
There is increasing debate concerning just how beneficial ADT treatment is in terms of survival, but it certainly has a down side in terms of sexual impairment and reduced physical function.
Additional research by doctors at the Harvard Medical School, Division of Urology, found that men with low testosterone levels had the most advanced prostate cancers. As men age, their testosterone levels fall severely and the incidence of prostate disease goes up accordingly. There is increasing evidence that shows that the higher the testosterone the lower the rates of prostate cancer and other problems.
One of doctors’ greatest fears about testosterone therapy has been that it may cause prostate cancer. But a new study shows that it doesn’t increase a man’s risk of prostate cancer – even if he has precancerous prostate cells. The study sheds light on the risks of testosterone therapy, which is used in men with low testosterone levels to help restore a man’s sexual function, mood, memory, even aspects of his physique – muscle mass, strength, body fat, bone density.
However, doctors have been concerned that testosterone therapy could trigger growth of prostate cancer – especially if a man already has precancerous cells in his prostate. The study involved 20 men who had precancerous cells in the prostate and 55 men who had no signs of these cells. After one year of testosterone therapy, researchers looked at prostate-specific antigen (PSA) levels for all the men. Rising PSA levels are an indication that a man may have prostate cancer. The PSAs were very similar for both groups – both before and after testosterone therapy.
These results indicate that testosterone therapy does not lead to prostate cancer and that men with a history of precancerous prostate cells may be able to safely take testosterone therapy.
However, hormone therapy successfully reduces the size of prostate tumors in 80% of men, but it does not kill cancer cells. For many men, it will be recommended as well as surgery. It is sometimes used before radiotherapy to reduce the size of the tumour.
Key
| May do some good |
| Likely to help |
| Highly recommended |
| May have adverse consequences |
| Reasonably likely to cause problems |
Glossary
Testosterone
The principal male sex hormone that induces and maintains the changes that take place in males at puberty. In men, the testicles continue to produce testosterone throughout life, though there is some decline with age. A naturally occurring androgenic hormone.
Hormones
Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.
Milligram
(mg): 1/1,000 of a gram by weight.
Serum
The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.
Acne
A chronic skin disorder due to inflammation of hair follicles and sebaceous glands (secretion glands in the skin).
Gram
(gm): A metric unit of weight, there being approximately 28 grams in one ounce.
Alopecia
Loss of hair.
Topical
Most commonly 'topical application': Administration to the skin.
Androgen
Any steroid hormone that increases male characteristics.
Benign
Literally: innocent; not malignant. Often used to refer to cells that are not cancerous.
Prostate
The prostate gland in men that surrounds the neck of the bladder and the urethra and produces a secretion that liquefies coagulated semen.
Cancer
Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.