replacement option for men entering middle age

Health care for men moving through their fifth and sixth decades brings them more frequently to the urologist.

There are several issues that a man entering his middle age may need addressed by a genitourinary specialist. These include prostate enlargement/urinary issues and cancer screening. Kidney stones are always a bother at any age, and many men may still have use of a vasectomy in these years. More and more often, though, we are seeing men for evaluation and treatment of decreasing testosterone: “low T.”

Reasons for this increase in these low T visits include an increased awareness of the condition, availability of improved treatment options and a general de-stigmatization of low T. Men with low T present with common symptoms that can be confused with normal aging. Many physicians believed, in the not too distant past, that low T was just that: a part of normal aging. We now feel differently. Low testosterone levels are linked to greater cardiac-specific mortality, bone density loss and insulin resistance, which can contribute diabetic management difficulty.

The main presenting symptoms of low testosterone include reduced energy and endurance, decreased or absent interest in sex and changes in body habits, which may include loss of muscle and increasing abdominal girth. If men with low T are able to drag themselves to the gym, they notice less results for their effort than in years gone by.

Causes of low T can include testicular atrophy, where the cells that produce testosterone begin to recede and go away. Stress and illness can cause decreased testosterone. Sleep disorders, most notably sleep apnea, can severely reduce testosterone production by interfering with hypothalamic-pituitary-testicular regulatory axis. The testosterone thermostat, if you will.

Step one in managing low T is to correctly evaluate the patient. After carefully listening to the patient’s symptoms, an early morning blood test of total and, often, free testosterone is essential to diagnosis. I cannot emphasize enough the importance of not trying to treat a man with normal testosterone with testosterone supplementation. His native production will go away as his internal “thermostat” senses elevated testosterone levels. His system then shuts down his own testicular production. This shut down may become irreversible if the testosterone supplementation is kept up without interruption for too long.

After we’ve established that a man has genuine low testosterone and it is causing him clinical problems, we need to settle on the most appropriate treatment. There are many options available. For our younger men, we often try a medicine with an extensive history of use in female infertility. Clomid basically resets the internal testosterone thermostat telling the testicles to make more T. This method has several advantages; men who may desire future fertility will typically not be rendered sterile by this medicine, and there is no gel that can get on others. That is a big plus if there are youngsters running around the house. The pill is off label and won’t be paid for by insurance, but it is generic and can be taken ½ a pill per day. Hopefully, it will be cost-competitive to other treatments.

Many men won’t get adequate improvement with Clomid. For these men, we need to go with more traditional T supplementation. The route chosen here depends on the patient, his insurance coverage and his social situation. There are the gels seen on TV. They are often covered by insurance and can be effective and easy to use. On the other hand, they can be pricey if insurance doesn’t help, and you don’t want to get them on women or children.

There is injectable testosterone cypionate; I like to use a low dose once a week. We teach the patient or a family member to do the injections. We follow these guys closely for a time to get optimal dosing levels. The big drawback is the need for weekly IM injections.

Next we have Testopel implants. These are placed in our office about every six months. We numb a spot on either hip and place about 15 “grain of rice” sized pellets. This gets good, sustained levels and is usually covered by insurance.

There are other innovative treatments in the pipeline for low T. Our research department often has trials of new or updated meds or delivery systems.

Many patients and spouses will worry about complications of testosterone replacement therapy. There were reports of increased stroke and heart risks associated with receiving testosterone. These concerns mainly trace their roots to a flawed VA system review. Properly restored testosterone levels are actually felt to be heart healthy. There is a risk, however, for well-replaced patients developing increased red blood cell counts. As the hemoglobin count rises above normal limits, a risk of reduced flow across narrowed blood vessels increases. We therefore follow our patients closely as we establish the optimal dosing schedule. We then typically check a CBC, testosterone and a PSA level every six months while on therapy.

Of course, the whole process doesn’t start until the man or a loved one asks the question as to whether low testosterone is a possible problem and comes in to be evaluated.

Dr. James Noble trained at the University of Texas Medical Branch in Galveston. He completed his urology training in 1990 at LSUHSC-S. He went on to join with the doctors who ultimately formed Regional Urology. He and his wife, Sylvia, who is also a physician, have three grown sons.

The youngest is attending medical school at LSUHSC-S.