MEN’S HEALTH and TESTOSTERONE REPLACEMENT THERAPY
It is estimated that today there are over 78 million Baby Boomers currently living in the United States. The Baby Boomers are the generation that was born between the years 1946 and 1964. As the Baby Boomers age, so comes with it a subsequent decline in their health and well-being.
Just as women experience declining estrogen levels in menopause from their 40’s through their 60’s, men experience a similar decline in levels of their primary hormone, testosterone, as they age. This decline in testosterone in aging men has been termed “andropause.” The loss of testosterone, which can happen to men as young as 25, is gradual, with testosterone levels dropping just 1 percent to 1.5 percent annually. Unlike the precipitous loss of estrogen which menopausal women face, the gradual loss of testosterone may take years to exact its mark on men. Declining testosterone levels in men can impact men’s health in a variety of ways – from declining energy levels to increased risk for cardiovascular disease.
Naturopathic physicians take a full individualized history from you to determine if you are experiencing symptoms of andropause. They most often spend up to an hour with you on your first visit to really get to know you as a person and to know your full history before starting with any laboratory tests or with any treatments. Andropause seems to be a multifactorial process, but most often occurs when testosterone levels in men decline with age. Symptoms of andropause may also be caused by or be mimicked by other conditions like adrenal fatigue, hypothyroidism and environmental toxicity. With lowered testosterone levels, not only can men have the unwanted symptoms of andropause like lack of libido, erectile dysfunction and a decrease in energy, but they can also be predisposed to developing other more serious conditions like cardiovascular disease, obesity, insulin resistance and diabetes, osteoporosis, and Benign Prostatic Hyperplasia (BPH).
Common physical and emotional symptoms are associated with andropause including: mental decline (irritability, depression, and anxiety), decline in libido, erectile dysfunction (difficulty attaining/maintaining erections), benign prostatic hyperplasia (BPH), fatigue, weight gain – especially in abdomen, and loss of muscle mass and muscle weakness
Simple blood tests, like a male hormone panel, and other specialized tests like a thyroid function test and adrenal function test, can determine the underlying cause of your andropausal symptoms. Other specialized tests like a Cardiovascular Risk Assessment can determine your risk of developing other conditions like cardiovascular disease and even insulin resistance or diabetes. Although medications are not a naturopathic physician’s first choice for treating the symptoms of andropause, naturopathic physicians do have prescription rights in the state of Arizona and may decide to prescribe you a medication if they feel it necessary. With the use of natural Bioidentical Hormone Replacement Therapy (BHRT) in conjunction with many other natural treatment options, like botanicals, nutritional supplementation, and acupuncture, andropause can be managed effectively and help men regain and attain optimal health as they age.
It is extremely valuable to have a work up done by someone trained and experienced in hormone replacement therapy. Too often patients seek the help of a general practitioner and receive hormone therapy that is not tailored specifically to the patient. This provides only suboptimal results leaving the patient disappointed in a therapy, that normally would have great potential for improving health.
How does low testosterone develop?
With normal aging, there is a decrease in production of testosterone by the testes. It is thought that this decline in testosterone is the single most important cause of andropause. Approximately 30% of men 60-70 years of age and 70% of men 70-80 years of age have low bioavailable or free testosterone levels. The first step in testosterone production begins in the area of the brain called the hypothalamus. Two hormones, which are secreted by the hypothalamus, namely FSH and LH, signal the testes to produce both sperm and testosterone, respectively. While it is estimated that a man is born with over 700 million Leydig cells (the cell responsible for making testosterone) in the testes, he loses six million of these cells yearly after the age of 20.
After testosterone is made by the Leydig cells in the testes, it is released into the bloodstream where it has many different fates. Some testosterone attaches to sex hormone binding globulin (SHBG) which helps to bind up excess testosterone and estrogen that are floating in the bloodstream. Additionally testosterone may be converted into other hormones via 2 distinct enzymatic pathways. In one pathway, testosterone is converted into dihydrotestosterone (DHT) through the action of 5-alpha reductase which has been found to be in especially high concentrations in the prostate gland. In another pathway, testosterone is converted directly into estrogen by the enzyme aromatase, which has been found to be in high concentrations in skin, fat, bone and brain cells.
Free testosterone, otherwise known as bioavailable testosterone, is the amount of testosterone that is not bound to SHBG or that is converted into other hormones. It is this free testosterone that is the small fraction of useable testosterone that has metabolic activity and therapeutic value within the cells. In andropause, the amount of free testosterone declines and the amount of SHBG actually increases. Thus, free testosterone becomes increasingly bound to this protein making already dwindling supplies of testosterone less effective.
Just as free testosterone levels are declining, levels of the enzyme aromatase tend to increase with age. Aromatase is found in high concentrations in fat cells, especially in the abdominal region, and converts testosterone into estrogen, further depleting testosterone stores and increasing estrogen levels. his can potentially lead to adverse effects seen with increasing estrogen levels, such as prostate enlargement and increased risk for prostate cancer.
Additionally, more free testosterone may be converted into DHT by the enzyme 5-alpha reductase in the prostate gland. DHT is the most potent form of testosterone, and stimulates the synthesis of specific proteins and causes new prostate cells to proliferate. The most widely accepted theory by conventional medical doctors regarding DHT suggests that DHT is the primary cause of abnormal cell growth in the prostate, leading to Benign Prostatic Hyperplasia (BPH) and cancer of the prostate.
However, this theory has been widely scrutinized and it is now believed that the growing imbalance between estrogen and testosterone levels in aging men also plays a substantial role in the development of BPH. I is known, however, that DHT plays a significant role in hair building and growth in men. HT is produced directly in the skin and is highest in concentration on the head. n normal amounts, DHT helps to produce and maintain healthy amounts of hair on top of the head. owever, excess DHT can lead to male pattern baldness commonly seen in aging men.
Adrenal fatigue can also cause similar symptoms as andropause. The adrenal glands are two glands that sit atop each kidney and are responsible for secreting hormones that control blood pressure, blood sugar regulation, and hormones of reproduction, including testosterone. f a person is under significant amounts of stress over a long period of time (weeks to years), this can lead to potential difficulties in the adrenal glands’ ability to produce enough hormones.
This can affect people in a variety of ways and can mimic or exacerbate the effects of andropause. For instance, such symptoms of both adrenal fatigue and andropause are fatigue, anxiety, depression, and weight gain. Adrenal function can be tested and hormonal balance can be restored through nutritional and synthetic supplementation.
Hypothyroidism is another condition that may mimic or actually exacerbate the effects of andropause. Your thyroid gland is located in the front of the neck and is responsible for secreting thyroid hormone which plays a role in maintaining body temperature, energy metabolism, weight control and heart function. Those with hypothyroidism can feel sluggish, fatigued and gain weight more easily, like as is seen in andropause. It is therefore important to have thyroid function tested to determine if it is a thyroid imbalance leading to certain symptoms or actually andropause.
Environmental exposures also cause andropause symptoms. As was discussed previously, declining testosterone levels and increasing estrogen both play an important role in the developing symptoms seen in andropause. There are certain compounds in the environment that men might not realize that they are ingesting, breathing and rubbing on their skin each day that might be contributing to or exacerbating their symptoms of andropause. These compounds can include plasticizers, organochlorides, bromated fire retardants (applied to prevent electronics, clothes and furniture from igniting), sunscreens, and heavy metals.
Environmental estrogens, known as “xenoestrogens,” arise as artifacts during manufacturing of plastics and other synthetic materials. Others are metabolites generated from pesticides or steroid hormones used to stimulate growth of livestock. Many of these estrogens, foreign to the human body, mimic the estrogen that men have in their body and by binding to the same receptors throughout the body, wreak havoc on reproductive function. This may lead to the decreasing testosterone levels seen in andropausal men or making the amount of free testosterone that men do have substantially weaker.
Bisphenol A (BPA) is a specific industrial chemical “xenoestrogen” that is found in the manufacture of food cans, milk containers, food storage containers and water supply pipes Recent research in Cancer Research showed that BPA can potentially encourage the growth of a specific type of prostate cancer cell thus leading to prostate cancer itself or cause mutations and lead to the progression or aggressiveness of existing prostate cancer.A study by the Lancet published in 1993 found that there was a correlation between decreasing sperm counts in the United States and 20 other foreign countries with the increasing amount of xenoestrogens found in the environment. n addition, the rate of testicular cancer, usually only affecting young men in their 20s and 30s has increased worldwide over the last 3 decades.
Cardiovascular Disease and Testosterone
Heart attack and stroke are the leading cause of death in the United States today. Heart disease is responsible for over 40% of all the deaths in the United States, more than all forms of cancer combined. Many forms of heart disease can be prevented or treated with healthy lifestyle choices and diet and exercise. Cardiovascular disease is caused by narrowed, blocked or stiffened blood vessels that make the delivery of blood and oxygen to your heart, brain and other parts of the body greatly diminished. Symptoms of cardiovascular disease include: chest pain, called angina, shortness of breath, and pain, numbness and coldness in the arms and legs. Most of the time, cardiovascular disease is not diagnosed until the condition has worsened to the point that someone has a heart attack, chest pain, stroke, congestive heart failure or sudden cardiac death. Therefore it is of the utmost importance to begin screening for cardiovascular disease earlier rather than later and discuss any questions about and any symptoms that you are experiencing with a doctor.
While cardiovascular disease can refer to many different types of heart or blood vessel problems, the term is often used to mean damage caused to the heart or blood vessels by atherosclerosis, a buildup of fatty plaques in arteries. Arteries are blood vessels that carry oxygen and nutrients from the heart to the rest of the body. Healthy arteries are flexible and strong. Over time, however, too much pressure in arteries can make the walls thick and stiff — sometimes restricting blood flow to vital organs and tissues. This process is called arteriosclerosis, or hardening of the arteries. Atherosclerosis is the most common form of this disorder. Atherosclerosis is also the most common cause of cardiovascular disease, and it’s caused by an unhealthy diet, lack of exercise, being overweight and smoking. All of these are major risk factors for developing atherosclerosis and, in turn, cardiovascular disease.
Another factor that plays a substantial role in the development of cardiovascular disease is declining testosterone levels seen in andropausal men. Men are more than twice as likely as women to develop cardiovascular disease. Pre-menopausal women have a lower risk of developing cardiovascular disease but this incidence rises after menopause. Thus, estrogen seems to play a protective role in the development of cardiovascular disease in women. Little attention has been paid to the role that testosterone plays in the pathogenesis of cardiovascular disease. As testosterone declines with advancing age, the prevalence of cardiovascular disease has been shown to increase. The more elderly population which has the highest cardiovascular disease prevalence has relatively low testosterone levels. Furthermore, males with cardiovascular disease have lower testosterone then men without.
Different patterns of cholesterol lipid levels and apoproteins, small molecules that carry cholesterol in the body, also play a role in the pathogenesis of cardiovascular disease. High total cholesterol, high LDL lipid levels, high triglycerides, and elevated lipoprotein-a have all been shown to be highly causative of cardiovascular disease, while high HDL has been shown to be protective. The majority of studies have shown that with higher testosterone levels the higher the HDL levels are and the lower the LDL, triglyceride and total cholesterol levels thus relating to a lower risk of developing cardiovascular disease.
Obesity and Testosterone
Weight gain seems to be an inevitable part of the aging process. This seems to be very highly related to the fact that men’s testosterone levels decline with age. The increase in weight is related to the frequent concomitant development of insulin resistance and diabetes that are often seen in andropausal men. High levels of insulin and cortisol, both needed for proper blood sugar regulation, along with decreased free testosterone levels in the aging male can lead to lipid accumulation. The lipid accumulation results in more deposition of visceral fat, especially in the abdominal region, rather than subcutaneous fat. This leads to the typical increase in waist-to-hip ratio (WHR) seen in aging men. Visceral fat has a high density of androgen receptors and when testosterone is in adequate quantities it helps to inhibit the accumulation of fat. However, with the natural diminution of testosterone in andropause this inhibition is slowed down and more visceral fat tends to accumulate. The situation is confounded by the fact that adipose tissue aromatizes testosterone into estrogen, further depleting testosterone in the aging male.
It has been shown that men who are deficient in testosterone given hormone replacement have reductions in visceral obesity and an improvement in their WHR. With testosterone replacement there also seems to be a reduction in other aspects of metabolic syndrome, including insulin resistance and diabetes and an increase in lean muscle mass.
Insulin Resistance, Diabetes and Testosterone
Insulin is a hormone that is responsible for the uptake of glucose into cells from the bloodstream after a meal. When people are insulin resistant, their muscle, fat, and liver cells do not respond properly to insulin. As a result, their bodies need more insulin to help glucose enter cells. The pancreas tries to keep up with this increased demand for insulin by producing more. Eventually, the pancreas fails to keep up with the body’s need for insulin. Excess glucose builds up in the bloodstream, setting the stage for diabetes. Many people with insulin resistance have high levels of both glucose and insulin circulating in their blood at the same time. Insulin resistance increases the risk for developing Type II Diabetes Mellitus and cardiovascular disease.
Although not the primary risk factor, decreasing bioavailable testosterone levels in men seem to play a substantial role in the pathogenesis of insulin resistance and diabetes. Numerous studies have consistently found a negative correlation between bioavailable testosterone and fasting glucose or fasting insulin – the lower the amount of testosterone found in men, the higher the fasting glucose and insulin. Both high insulin levels and low testosterone separately predict the onset of type 2 diabetes. People with diabetes appear to have lower testosterone levels than normal males. A study of 110 men with type 2 diabetes found that the lower the level of testosterone in men, the worse that they were able to control their blood sugars. Intervention studies with testosterone treatment within the physiological range document improved insulin sensitivity in elderly and obese men.
Benign Prostatic Hyperplasia (BPH)
Benign Prostatic Hyperplasia (BPH) is a condition of excessive proliferation of prostate cells and an enlarged prostate gland that probably occurs as part of the normal aging process in men. The prostate gland sits beneath the bladder and surrounds the urethra — the tube that drains urine from the bladder. When it becomes enlarged, the prostate can put pressure on the urethra and cause difficulty urinating.
With aging it is almost universal in men to have an enlarged prostate gland. It is most commonly seen in men over the age of 40, and 50% of men over the age of 50 have enlarged prostates. Although an enlarged prostate, or benign prostatic hypertrophy (BPH), may not cause men any difficulties in everyday functioning, often it can lead to problems with urination such as decrease in force of urination, sensation of incomplete voiding, increased frequency in urination, and dribbling of urine.
As men age, testosterone in the body is converted more into dihydrotestosterone (DHT) in the prostate which has a direct relation to increasing prostate size. Sex hormone binding globulin (SHBG) also plays a role in the development of BPH and of many changes that occur in andropause. There is an SHBG receptor on prostate gland cells which allows steroid hormones, like testosterone and estrogen, to bind and exert their function on the prostate. DHT has the highest binding affinity for SHBG of any substance, even of testosterone and estrogen. Because it does have the highest binding capacity for SHBG on prostate cells and is most closely associated with the development of prostate enlargement, as testosterone is selectively converted more into DHT as men age, this may lead to and exacerbate BPH.
Osteoporosis
One of the most destructive effects of aging is the loss of muscle and bone mass. While the loss of bone mass, or osteoporosis, is now widely recognized as a significant factor in robbing elderly women of their ability to walk, osteoporosis is also a significant health concern for older men. In addition, the loss of muscle tissue, or sarcopenia, is now finally being recognized as a major debilitator of both men and women. In men, both sarcopenia and osteoporosis can be linked to the decline in testosterone and other steroid hormones.
A study of 403 healthy men aged 73-to-94 years, in the Journal of Endocrinology and Metabolism examined the hypothesis that the decreases in muscle strength, bone mass and body composition seen in aging males are related to falling testosterone levels. The researchers measured the men’s hormonal levels and ran multiple tests to gauge their body composition, muscle strength and bone mass. Their findings were that muscle strength and bone mass were at optimal levels in men with the highest levels of free testosterone, leading the authors to state that there are a number of clinical problems present in older men that may be related to testosterone deficiency, including reduced muscle mass, changes in body composition, and loss of bone mass density.
Another study in the Journal of Endocrinology and Metabolism showed that older men with total testosterone or estrogen deficiency were more likely to be osteoporotic and those with osteoporosis were more likely to be testosterone or estrogen deficient. Subsequently rapid bone loss in the hip joint, one of the most commonly fractured joints in the elderly, was more likely to be observed in men with total testosterone deficiency.
PSA and Prostatitis
With aging, it is almost universal in men, to have an enlarged prostate gland. It is most commonly seen in men over the age of 40, and 50% of men over the age of 50 have enlarged prostates. Although an enlarged prostate, or benign prostatic hypertrophy (BPH), may not cause men any difficulties in everyday functioning, often it can lead to problems with urination such as decrease in force of urination, sensation of incomplete voiding, increased frequency in urination, and dribbling of urine.
As men age, testosterone in the body is converted more into dihydrotestosterone (DHT) in the prostate which has a direct relation to increasing prostate size. Simple blood tests and physical examination of the prostate can help naturopathic physicians determine if men have BPH or a more serious condition like prostate cancer. Naturopathic modalities like botanical medicine, nutritional supplementation and acupuncture can all help men with this condition.
Although BPH is a rather benign condition, it has similar signs and symptoms to prostate cancer which may be a more serious diagnosis in men. Like BPH, prostate cancer can be asymptomatic and it may not cause any problems in men until it is advanced in its progression. However, it may also lead men to have urinary urgency, hesitancy, need to urinate during sleep, poor urinary stream, and dribbling. Prostate cancer accounts for 70% of all male cancers and only lung cancer has a higher mortality rate. Incidence also increases with age, with 80% of new cases occurring after 65 years of age. It is important for men to begin screening for prostate cancer at age 50 and at 40 years in African-Americans or in men who have a family history of prostate cancer. To help naturopathic physicians screen for prostate cancer and other illness they may perform simple blood tests, a physical examination of the prostate, along with a Men’s Wellness Exam.
Prostatic Intraepithelial Neoplasia (PIN), is a condition in which the cells on the prostate gland’s surface divide more rapidly than the rest of the prostate cells. Research shows that men diagnosed with PIN have a sharply increased risk of developing prostate cancer. It has been postulated that there seems to be an inflammatory component to this condition that typically responds favorably to naturopathic treatments. Recent literature has shown that natural cyclooxygenase (COX) inhibitors, like Zyflamend and Curcumin, have been linked to decreasing the amount of inflammation in not only the body, but specifically the prostate gland itself, and thus helping to reverse PIN. Naturopathic physicians use tests like IgG Food Intolerance Testing, C-reactive protein, and other tests designed to measure the amount of inflammation in your body, and doing so can help them tailor individual anti-inflammatory diets and natural protocols to decrease this inflammatory process taking place.
Prostatitis is an inflammation of the prostate gland that can often lead to pain in the low back, abdomen or the pelvic region. It can also lead to urinary difficulties like difficulty urinating, frequency and urgency of urination, and the need to urinate during sleep. Prostatitis can be classified as either bacterial or non-bacterial prostatitis, often presenting with similar signs and symptoms. Most conventional physicians believe that cases of prostatitis are of the bacterial form and treat prostatitis with broad spectrum antibiotics, like Ciprofloxacin. What often occurs is that the symptoms of prostatitis and the general inflammation of the prostate are not made better by this treatment. As most naturopathic physicians would agree, prostatitis is not caused by bacteria in the prostate but most frequently due to fungus, like Candida, in the prostate – hence why prostatitis is not alleviated by antibiotics. In fact, it is estimated that prostatitis is of the non-bacterial form 95% of the time. Naturopathic physicians use treatments like both natural and, if necessary, prescription anti-fungals, botanical medicine, and omega fatty acids to treat both the underlying infection and inflammation of the prostate causing the prostatitis.
Often times, food allergies over time can lead to the inflammation seen in prostatitis and can often exacerbate the underlying fungal infection occurring. The reduction in consumption of these foods in conjunction with the aforementioned natural treatments can help to reduce the severity and the incidence of prostatitis. Low grade chronic prostatitis can persist, without any physical symptoms, other than an elevation in prostate specific antigen (PSA).
Prostate Specific Antigen (PSA) is a controversial, but informative blood laboratory test that is used to determine the degree of underlying inflammation occurring in the prostate gland. While most conventional physicians would agree that only PSA values over 4.0 up to a level of 10.0 are indicative of serious prostate conditions, naturopathic physicians take a more cautious approach. Naturopathic physicians believe that a PSA level of 1.0 or greater indicates some degree of chronic prostatitis and that even PSA levels from 0-4, what is considered “normal” amongst conventional doctors, could still potentially be prostate cancer. As PSA levels climb, the underlying inflammation and/or chronic infection becomes worse in the prostate and predisposes a man to developing prostate cancer later in life. It is estimated that men with a PSA between 2 and 4 have a five to nine times greater incidence of developing prostate cancer within the next subsequent 10 years. Therefore, naturopathic physicians work with you to not only screen for this underlying chronic inflammation that is occurring in the prostate but also to treat the underlying inflammation/infection using natural therapies described above.
Methods of Administration
The methods of administration of BHRT of testosterone include oral administration, creams or gels, transdermal patch, intramuscular injections, and the implantation of pellets containing testosterone under the skin of the buttocks. Oral testosterone is the most unfavorable method of administration, as it is poorly absorbed by the body. Most of the oral testosterone is carried from the intestines to the liver by the portal vein where the liver inactivates a sizeable portion of the hormone. An oral micronized form of testosterone suspended in oil can also be used which is slightly better than the non-micronized form, however it is still poorly absorbed when compared to the other routes of administration.
Hormone Replacement Therapy
In recent years, hormone replacement therapy has gained in popularity amongst andropausal men and menopausal women to improve their hot flashes, sexual function, mood, sense of well being, muscle density, bone mass and strength. In addition, some hormone therapy has been found to be beneficial in preventing heart disease, diabetes, and Alzheimers Disease. There is a growing trend over the last decade for both men and women opting for the use of bioidentical, compounded natural hormones for the treatment of andropause and menopause, respectively.
The testosterone, estrogen, and progesterone used in the bio-identical hormone replacement therapy (BHRT) is identical to that produced in the human body. Although BHRT have long been utilized in other countries, the United States has predominantly used synthetic hormones for the past 40-50 years beginning with the introduction of oral contraceptives in the early 1960s.
The uniqueness of the compounded bio-identical formulations are what makes it so attractive to prescribers and users alike. The ability to alter the dose to each individual does not compare to the two to maybe three options that pharmacies can offer to relieve the same symptoms for everyone. Each formulation prescribed by your physician is easily altered to increase the dose when needed to help ease symptoms or reduce levels easily if someone is looking to go off of the hormones.
What is also the most unique to these formulations in women, is the utilizaiton of both estradiol with estriol. Estriol is well known for its weak estrogenic activity compared to the more potent estrogens the body produces, estradiol and estrone. The advantage of including estriol in your hormonal formulation is that it has the ability to bind with the estrogen receptors on the breast cells more weakly than estradiol. Therefore, it can actually block the stronger estrogens from binding to the breast cells and subjecting them to the higher estrogenic activity which can put some women at risk for cancer.
Are labs required?
Before men or women start with hormone replacement therapy, laboratory tests are necessary to determine if there is a physiological need for hormone replacement. For men both free and total testosterone are measured, along with dihydrotestosterone(DHT) and sex hormone binding globulin (SHBG), Prostate Specific Antigen(PSA), DHEA-S, and Cortisol .
For women we like to check a hormonal baseline before administering hormones. We often test for estradiol, estrone, progesterone, total testosterone, free testosterone, cortisol AM and DHEA-S amongst other general labs if they haven’t been completed. For women, a risk assessment for estrogen and progesterone sensitive cancers must be considered and a exam performed, if not up -to-date before beginning hormone replacement therapy.
If hormone levels come back within normal limits, hormone replacement therapy is not likely necessary and they may be a better candidate for other therapies. However, if a man or woman is experiencing symptoms of andropause or menopause and they have low levels of hormones, hormone replacement therapy may be initiated.
ROUTES OF ADMINISTRATION
The methods of administration of hormone replacement therapy include oral administration, application of a topical creams, intramuscular injections, and the implantation of pellets under the skin. The route of administration determined is based on the individuals personal history and symptoms, blood work and personal preferences. Below is a brief description of options available.
ORAL ADMINISTRATION
LOZENGES/TROCHES: This hormonal preparation is a combination of oral and sublingual absorption which allows hormones to release in small doses into the bloodstream. Although some hormone is lost via normal metabolism as it passes through the liver, lozenges are compounded in strengths designed to overcome this disadvantage.
TOPICALS
CREAMS/GELS: Creams are often the most favorable route of administration of BHRT, due to lack of discomfort of an injection, and ease of application. They work best if applied daily on a particular schedule and are applied to the thin skin of certain areas of the body, with the preferred site for men, the posterior scrotum. These are the most effective as they avoid the pass through the liver and are absorbed directly into the bloodstream. In addition, they seem to mimic the natural rhythm of testosterone secretion that occurs the human body throughout the day.
INTRAMUSCULAR INJECTIONS
Testosterone is the only hormone that is injected and it is a great option for those who have low testosterone on their blood work and symptoms of low libido . This combination of blood work and symptoms can warrant testosterone replacement which can be made easy with weekly injections.
PELLETS
A great option for men is hormone pellet therapy. Hormone pellet therapy is customized to the needs and labs of each patient. Patients have the pellets placed every 3-6 months and do not have to think about a daily application. The theory behind this method is that the body will draw from the pellets what it needs creating a stable balance of delivery. The pellets are about the size of a piece of long grain rice and are placed just under the skin in the gluteal region.
Does Testosterone replacement increase risk for Prostate cancer?
For men a Prostate Specific Antigen test (PSA) will also be run before beginning hormone replacement therapy to determine if there is a risk for developing prostate cancer while supplementing with testosterone. There are mixed opinions in the medical field regarding the use of BHRT and its relationship to developing prostate cancer. Some experts believe that there is a stronger risk of developing prostate cancer while using testosterone, while others agree that testosterone does not cause prostate cancer. Clinical trials have demonstrated the latter, showing that PSA, the laboratory value most indicative of a potential cancerous lesion of the prostate, does not rise over 3-5 years of use of testosterone replacement therapy. These same researchers showed that prostate cancer seems to develop most commonly in older men when their testosterone levels are actually lowest versus highest. Despite the evidence, we do not suggest testosterone replacement in men who have a personal history of prostate cancer,at this time.
Erectile Dysfunction (ED)
The treatment of ED with natural medicine is very effective nearly 100% of the time. At the root of the problem exists two issues. One, most men with ED have extremely low testosterone. Once identified with lab testing and appropriately treated with testosterone replacement therapy, ED improves in most men. The second most common cause is circulation. Again, using natural therapies such as L-arginine and pycnogenol, have shown 80% improvement in ED in 4-8 weeks. This is without the use of hormone replacement therapy. Obviously the combination of both ideas leads to improvement in nearly all patients suffering with ED.
Rx Treatment for Impotence
Some patients may still benefit from the use of the following common prescriptions for ED including, Viagra (Sildenafil), Cialis (Tadalafil), and Levitra (Vardenafil). These drugs all work essentially the same way, although Cialis has been shown to last longer than the other medications used for impotence and erectile dysfunction. These medications work by increasing nitric oxide in the penis by inhibiting an enzyme called phosphodiesterase which normally breaks down a chemical compound called cGMP. This helps to relax arterial walls in the penis, allowing for initiation and maintenance of erection. Common side effects of these drugs include headache, flushing of the face and/or chest, bluish visual tint, priapism (an erection lasting longer than 4 hours), and incomplete or insufficient erection. These drugs should not be used with other nitrate drugs, such as nitroglycerine, and should be used with caution if combined with blood pressure medications or if you have a history of congestive heart failure, angina, or heart attack.
Tri-Mix Injections or Intracavernosal Injection
An intracavernous injection (aka Tri-Mix injections), according to the American Urologic Association, is the most effective non-surgical treatment for ED. Injections into the penis, unlike oral medications, trigger an automatic erection. Injection can be done by the individual 5 minutes prior to sexual activity and should last for no more than 1 hour. Injection is considered third line to be used if natural or oral therapy fails. Compounds that can be injected include alprostadil, papaverine, and phentolamine. Alprostadil and phentolamine are the most common agents used as monotherapy. However, combination therapies are used to increase efficacy and decrease side effects. Combination therapy includes Tri-Mix and Bi-Mix. Both products are not commercially available and must be compounded by specialty pharmacies. Below is a description of the medications that are in Tri-Mix and Bi-Mix including mechanism, dose and side effects of each agent.
Combination Therapy
Bi-Mix: Papaverine + Phentolamine
Bi-Mix was first introduced by a study in 1985 that showed a success rate of 71% amongst 250 patients that were given 1mg of phentolamine mixed with 30mg of papaverine. In 1987, 2 more studies were published. One study showed that phentolamine mixed with papaverine had a 72.9% success rate verse 20% with papaverine alone. In another study, papaverine mixed with phentolamine was examined for a follow up of 26 months. Only 13% of the patients failed to respond to therapy.
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– Usual prescribed strength: Papaverine 6-25mg + Phentolamine 0.05-2.0mg/ml
Tri-Mix: Papaverine, Phentolamine, Alprostadil
Tri-Mix is a compounded medication the combine’s papaverine, phentolamine and alprostadil in one vial to achieve maximum efficacy, lower incidence of pain, and lower cost per dose. Studies have been done that have shown the efficacy of all three agents combined into one formulation. Combination therapy was first introduced in 1991 by Bennett and his colleagues who demonstrated a success rate of TriMix of 92% in 116 patients. Tri-Mix is often reserved for patients who fail alprostadil (PGE-1), fail Bi-Mix or for patients with severe penile pain from prostaglandin E1. Since Tri-Mix uses lower doses of alprostadil, penile pain often subsides.
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– Usual prescribed strength: Papaverine 18-25mg + Phentolamine 1.0-2.0mg + Prostaglandin E1 10-25mcg/ml
Quad-Mix: Papaverine, Phentolamine, Alprostadil, Atropine
Quad-Mix includes the addition of atropine which may work synergistically to cause smooth muscle relaxation in the penis. In a study conducted by Israilov and colleagues, 13 patients that failed tri-mix had a positive response to quad-mix. Seven (53.8%) of the patients responded successfully with the addition of atropine.
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– Usual prescribed strength: Papaverine 20-25mg + Phentolamine 1.5-2.0mg + Prostaglandin E1 20-25mcg + Atropine 0.02-0.08mg/ml
