Codeine. An Unusual Cause of Ejaculatory Failure.
Dr Andrew Rynne.
Delayed ejaculation or so-called anorgasmia is a common male sexual dysfunction. In order of frequency it comes third to erectile dysfunction and premature ejaculation. It can be a deeply frustrating and devastating problem for which there are many causes. Drugs, both illicit and prescribed are common culprits. Common among the latter are all antidepressants and all antipsychotics. Not so well known however is Codeine. This over the counter addictive medicine is a major cause of ejaculatory incompetence. Yet very few people seem to realise it.
Just because it’s easy to get – usually without a prescription, this does not mean that codeine is just another Headache Medicine like paracetamol or aspirin. Far from it! Codeine is classified as an opioid. In other words its effects are not on the peripheral nervous system but on the brain chemistry itself. Any drug that has the potential to interfere with brain chemistry also has the capacity to bring about some serious sexual dysfunction and other problems..
Think of it this way: Messages are constantly been sent around your central nervous system via chemical known as neurotransmitters. This sophisticated communications system relays feelings of pleasure from your penis up to your brain. When your brain has had sufficient of this it relays a message to your ejaculatory ducts to ejaculate or reach orgasm.
But like all sophisticated systems it is easy to upset it.
Any drug that has a central brain action and the capacity to alter brain chemistry can also cause major disruption to messages to and from the brain. This in turn brings about a numbing of feelings from penis to brain such that the brain is insufficiently stimulated to respond with a message to ejaculate. When this happens there is but one solution – discontinue taking the offending medicine.
Indeed there are many other good reasons to discontinue taking codeine on regular bases. It is addictive. It causes a strain on your liver. And now as we have seen, it can cause major disruption to healthy sexual functioning. I have found in practise that it is sometimes very difficult to sell this idea of discontinuing codeine. Like nicotine and all addictive substances, codeine infuses in its victims a built-in resistance to the notion of quitting.
And yet quitting is not difficult if taken in easy bite-sized stages. By reducing the dose by 1/10 th per week over ten weeks most people succeed in quitting very easily. And just look at the advantages! Release from the tyranny of having to take a drug every day is one. Reduction of chronic liver damage is another. And now as we have just seen, return of normal healthy sexual functioning is perhaps greatest of all.
More information available at: www.doctorrynne.com
Sunday, August 21, 2011
Monday, August 8, 2011
Understanding Performance Anxiety Erectile Dysfunction
Understanding Performance Anxiety Erectile Dysfunction.
Performance anxiety is the commonest cause of erectile dysfunction in young men. This applies across all cultures, socio-economic groups and educational levels reached. It is a universal fact. And still it remains poorly understood. Most men, on being told that their problem is performance anxiety, want to reject such a suggestion and want you the doctor to come up with an alternative diagnosis. Sometime even the consultation can end in conflict.
In order to become sexually aroused a man’s subconscious brain needs to send a message to his penis. This signal is to ask the penis to fill with blood and get ready for action. If in the meantime the man’s mind is entertaining negative thoughts, however slight or niggling, about the state of his penis, then these subconscious messages are blocked and no erection results. For the system to work there must be no negative thoughts whatsoever. Only desire and relaxed pleasure work.
When a doctor tries to explain this to a man the patient’s immediate reaction often is to reject any such suggestion. He does this because he makes the following incorrect assumptions:
• Performance anxiety is the man’s own fault. That is not correct.
• Performance anxiety is difficult to treat. That is not correct.
• Performance anxiety is a sign of weakness and only affects wimps. That is not correct.
What young men often do not seem to understand is that all other causes of erectile dysfunction, in their age group, are relatively rare. These would include things like venous leek -- extremely rare in my experience. Indeed I have never seen a case in all my years of medical practise. Diabetes – very easy to rule in or to rule out. Medications or drug abuse – again easy to exclude. Neurological diseases or other chronic illness. Again this should be blindingly obvious as a cause of ED. In short, nine times out of ten, performance anxiety is the candidate of first choice but is often the one that is most difficult to sell.
Doctors or counsellors who would assume to treat sexual dysfunction in younger men need to be very aware of how the notion of performance anxiety can often be met with hostility. Often indeed it is necessary to come at this diagnosis via a circuitous rout. It is often wise to list all possible causes and to rule them out one by one such that the client is left with on reasonable alternative explanation for his problem other that to accept the cause as being our old friend, performance anxiety. Because until such time as this acceptance begins to dawn on him, there can not be any cure.
For more information about performance anxiety please visit www.doctorrynne.com
Performance anxiety is the commonest cause of erectile dysfunction in young men. This applies across all cultures, socio-economic groups and educational levels reached. It is a universal fact. And still it remains poorly understood. Most men, on being told that their problem is performance anxiety, want to reject such a suggestion and want you the doctor to come up with an alternative diagnosis. Sometime even the consultation can end in conflict.
In order to become sexually aroused a man’s subconscious brain needs to send a message to his penis. This signal is to ask the penis to fill with blood and get ready for action. If in the meantime the man’s mind is entertaining negative thoughts, however slight or niggling, about the state of his penis, then these subconscious messages are blocked and no erection results. For the system to work there must be no negative thoughts whatsoever. Only desire and relaxed pleasure work.
When a doctor tries to explain this to a man the patient’s immediate reaction often is to reject any such suggestion. He does this because he makes the following incorrect assumptions:
• Performance anxiety is the man’s own fault. That is not correct.
• Performance anxiety is difficult to treat. That is not correct.
• Performance anxiety is a sign of weakness and only affects wimps. That is not correct.
What young men often do not seem to understand is that all other causes of erectile dysfunction, in their age group, are relatively rare. These would include things like venous leek -- extremely rare in my experience. Indeed I have never seen a case in all my years of medical practise. Diabetes – very easy to rule in or to rule out. Medications or drug abuse – again easy to exclude. Neurological diseases or other chronic illness. Again this should be blindingly obvious as a cause of ED. In short, nine times out of ten, performance anxiety is the candidate of first choice but is often the one that is most difficult to sell.
Doctors or counsellors who would assume to treat sexual dysfunction in younger men need to be very aware of how the notion of performance anxiety can often be met with hostility. Often indeed it is necessary to come at this diagnosis via a circuitous rout. It is often wise to list all possible causes and to rule them out one by one such that the client is left with on reasonable alternative explanation for his problem other that to accept the cause as being our old friend, performance anxiety. Because until such time as this acceptance begins to dawn on him, there can not be any cure.
For more information about performance anxiety please visit www.doctorrynne.com
Online Medical Consultation Here to Stay
Online Medical Consultation Here to Stay.
Being in General Practise for thirty years or more has, as you can imagine, thought me a thing or two about people and their relations with doctors. Here are some of the things I learned:
• People often don’t trust doctors but are afraid to challenge them. They are afraid to ask for a second opinion.
• People often don’t understand doctors or what they are trying to tell them.
• In the confusion of the consulting process people find it difficult to concentrate on what the doctor is saying. Therefore, they may afterwards appear to be almost deliberately non-compliant.
• For reasons perhaps known only to them, people can withhold vital information from their doctor or simply not tell the truth. This may render the entire consultation worthless.
• There are some things that all of us may find impossible to talk about face to face with another human being. Sexuality may be one such subject.
Given all these natural fault lines that appear in many doctor-patient consultations, it occurred to me that the Internet might be the perfect medium through which to allow people augment and redress this often flawed process. Online medical consultation is not designed to and never will replace the traditional doctor patient physical interaction. It can however bring clarity and lend valuable support to this process. When a person commits to Online consultation they:
• Have the required time and space to concentrate on their complaints and symptoms.
• Are less inhibited about discussing difficult topics.
• Are not afraid to argue their point of view.
• Are less inclined towards untruthfulness.
• Have the time and space to absorb all that is being said to them.
• Can seek clarification until they fully understand their diagnosis and its implications.
Whether we like it or nor, and personally I know many doctors who don’t like it, people will use the Internet to try and diagnose and even treat their own illnesses. Or at the very least will go to their doctor pre-loaded with a lot of Google information and misinformation. The Internet has now irrevocably infiltrated the doctor-patient process. It is up to us in the profession to try and make this development as innocuous as possible.
For more information about Online Doctors and e-Consultations please visit: www.doctorrynne.com
Being in General Practise for thirty years or more has, as you can imagine, thought me a thing or two about people and their relations with doctors. Here are some of the things I learned:
• People often don’t trust doctors but are afraid to challenge them. They are afraid to ask for a second opinion.
• People often don’t understand doctors or what they are trying to tell them.
• In the confusion of the consulting process people find it difficult to concentrate on what the doctor is saying. Therefore, they may afterwards appear to be almost deliberately non-compliant.
• For reasons perhaps known only to them, people can withhold vital information from their doctor or simply not tell the truth. This may render the entire consultation worthless.
• There are some things that all of us may find impossible to talk about face to face with another human being. Sexuality may be one such subject.
Given all these natural fault lines that appear in many doctor-patient consultations, it occurred to me that the Internet might be the perfect medium through which to allow people augment and redress this often flawed process. Online medical consultation is not designed to and never will replace the traditional doctor patient physical interaction. It can however bring clarity and lend valuable support to this process. When a person commits to Online consultation they:
• Have the required time and space to concentrate on their complaints and symptoms.
• Are less inhibited about discussing difficult topics.
• Are not afraid to argue their point of view.
• Are less inclined towards untruthfulness.
• Have the time and space to absorb all that is being said to them.
• Can seek clarification until they fully understand their diagnosis and its implications.
Whether we like it or nor, and personally I know many doctors who don’t like it, people will use the Internet to try and diagnose and even treat their own illnesses. Or at the very least will go to their doctor pre-loaded with a lot of Google information and misinformation. The Internet has now irrevocably infiltrated the doctor-patient process. It is up to us in the profession to try and make this development as innocuous as possible.
For more information about Online Doctors and e-Consultations please visit: www.doctorrynne.com
Major Breakthrough in Treating Female Sexual Dysfunction
Major Breakthrough in Treating Female Sexual Dysfunction.
This low level of male hormone in post-menopausal women can give rise to many undesirable consequences. Indeed it is now suggested that testosterone may be the “missing link” in the management of menopausal symptoms not otherwise responding to standard HRT. To date this in the main consisted of oestrogen and progesterone. Included here are hot flushes, depression, osteoporosis and the sexual dysfunctions of vaginal dryness, dyspareunia, anorgasmia and low or no libido.
Testosterone for the Lady.
Dr Andrew Rynne.
People naturally associate the hormone testosterone, also called androgen, with men. It’s what makes us so nasty, so aggressive, so driven, so bald, so hairy and so sex mad. Isn’t that so? What very few people don’t realise though is that testosterone also plays a vital role in female sexual functioning. To be healthy, a woman needs to have androgen levels of approximately one tenth of that of young men. This they produce in their ovaries and adrenal glands. It plays a part in many things of which sex drive or libido is but one.
It may go against the grain to associate testosterone with femininity. After all, in the main when compared to men, women are gentler, better at empathising, more intuitive and more patient than men with their raging testosterone. So how could they possible need this stuff that enjoys such bad press? Recent studies have shown that post menopausal women not only lack oestrogen and progesterone but testosterone as well.
This low level of male hormone in post-menopausal women can give rise to many undesirable consequences. Indeed it is now suggested that testosterone may be the “missing link” in the management of menopausal symptoms not otherwise responding to standard HRT. To date this in the main consisted of oestrogen and progesterone. Included here are hot flushes, depression, osteoporosis and the sexual dysfunctions of vaginal dryness, dyspareunia, anorgasmia and low or no libido.
So how much testosterone replacement do ladies need? The quick answer is not a lot. At most her optimum levels of androgen will be from one seventh to one tenth of that of men. So, if a man requires on average 50mg of testosterone delivered daily via a gel call Testogel, then a woman’s requirement will be one tenth of this or 5mg of testosterone daily. A handy way to think of this is that if a man uses one tube of Testogel every day then the same tube of gel should last a woman one week. A little “toothpaste” sized smear on the inside of her forearm every day should do the job nicely.
Doctors who “approve” of testosterone replacement therapy for women are still thin on the ground and some of those like to try and make things complicated. Blood tests, for example, to measure the levels of testosterone that a post-menopausal woman might have, are largely a waste of time and money. They contribute not a jot to the diagnosis. Likewise, expensive specially compounded “female” testosterone replacement therapy will do a lot more for the doctor’s bank account than it will for client’s wellbeing. There is nothing wrong with existing pharmaceutically manufactured androgen gels as given to men.
It is in practise quite simple. All you need do is ask yourself some simple questions: Do you have post-menopausal symptoms not relieved with standard HRT? In particular, do you have sexual dysfunctions like vaginal dryness and loss of libido? If the answer to this is “yes” then try some testosterone replacement therapy at a does of about one tenth of that for a man? Did that improve things for you? If yes then continue if no then discontinue. Now, isn’t that nice and simple? Why complicate things?
To find out more about Testosterone treatments available for women please visit www.doctorrynne.com
Tuesday, July 19, 2011
Testosterone Replacement Therapy – What You Need to Know
Testosterone Replacement Therapy – What You Need to Know.
Up to a few years ago, it was common practise for those seeking testosterone replacement therapy that they be required to undergo a range of expensive and not altogether reliable hormonal assays. Recently it has emerged that not only were these tests not necessary but also that they added nothing to the decision making process as to whether one might benefit from TRT or not. Today, most enlightened doctors, rely on presenting symptoms and complaints, not on blood tests, when making this decision.
I believe that as time goes on TRT will eventually become mainstream treatment for some men troubled by their ageing process. In the meantime, if you would like to know more about this exciting subject, then please visit my website and ask me any questions that you might have. It would be my privilege to try and help you. Thank you for your interest.
Find out more about Testosterone Replacement Therapy at www.doctorrynne.com
Dr Andrew Rynne.
The news emerging about Testosterone Replacement Therapy (TRT) keeps getting better all the time. Recent published clinical trials show benefit for this treatment far beyond boosting libido or reducing erectile dysfunction. It is now becoming apparent that TRT has the potential to not only prolong life but to also improve the quality of that prolonged life. In addition to this exciting news, criteria for deciding who might benefit from this treatment have been greatly simplified. And yet, for reasons that I will try and explain later, most doctors remain opposed to this potentially life saving treatment.
It has now been shown unequivocally that by raising testosterone levels in your blood you can:
Ø Reduce insulin requirements in people suffering from type 2 diabetes.
Ø Reduce blood lipid levels and thus the need to take medications for this purpose.
Ø Improve coronary artery disease and its symptoms of angina pectoris.
Ø TRT also reduces visceral fat or “pot belly” so common in older men.
Ø Cognitive function or brain power is improved by keeping testosterone levels up.
In spite of all these clinically proven advantages for taking TRT must doctors remain opposed to it today. This is due to their harbouring deeply ingrained erroneous notions about raised testosterone levels and the incidence of prostate cancer. Metastatic prostate cancer may be temporarily checked by reducing testosterone levels to zero. This however does not mean that the corollary is true, that raised testosterone increase the incidence of prostate cancer. Clinical studies designed to show this to be the case have all failed to do so. Prostate cancer is a disease of older men with declining testosterone levels and to suggest that raised levels could in any way increase prostate disease is to fly in the face of reason and science.
Find out more about Testosterone Replacement Therapy at www.doctorrynne.com
Thursday, June 30, 2011
Dhat Syndrome or Loss of Semen Disease
Dhat Syndrome --- Loss of Semen Disease.
A Uniquely Indian Neurosis.
Dr Andrew Rynne.
Being is the business of Sexual Medicine, particularly Internet Sexual Medicine, I had long been aware of a syndrome unique to India and her sub-continent. And while being aware of it and my own obvious inability to do anything about it, I did not know that this culture bound malady actually had a name and was well described in the medical literature. One learns something new every day.
Dhat Syndrome is a sexual neurosis unique to India, Pakistan, Sri Lanka, Nepal and areas where the Hindu culture prevails or used to prevail. Some ancient teachings in that noble culture portray semen as a vital life giving force, as essential to life as blood itself. Variants of Dhat Syndrome do occur further east and in the orient, though here its prevalence is less obtrusive. In parts of India the prevalence of this very debilitating neurotic disorder may be as high as 30% which is very high indeed. This figure however needs further analysis.
The following symptoms would be classical for Dhat Syndrome:
(1) A morbid preoccupation with the loss of semen. This loss, or perceived loss, may arise from the imagined passage of semen in the urine. The loss of semen through spontaneous nocturnal emissions. And of course, perceived the most damaging of them all -- the loss of semen through masturbation.
(2) Sexual dysfunction or perceived dysfunction – erectile dysfunction and premature ejaculation.
(3) Unhappiness about the size or the shape of his penis. A conviction that his penis is shrinking.
(4) Fatigue, lassitude, tiredness, weakness, anxiety, depression and classically guilt about masturbation.
(5) Worry about future potency, fertility and an ability to father children.
(6) A preoccupation with pre-ejaculation discharge.
(7) An attitude of helplessness and dependency.
The overall incidence of Dhat Syndrome in India is between 10 and 30% which, as stated earlier, makes it almost endemic. This figure of course depends on how the researcher defines the condition. To reach that higher incidence of the disease, I suspect the statistician would need to utilise a very broad definition of Dhat Syndrome to include all young men with more than a passing concern about semen loss.
Then, although the literature does not say much about this, there are varying degrees or grades of Dhat Syndrome. Indeed it could well be the subject of a future Doctorate Degree in Medicine. This sexual neurosis could be graded from one to five in classic fashion. At one end of the spectrum are young men overly preoccupied with the ‘damage’ they are doing to themselves through masturbation. These men may be otherwise unscathed.
At the other end of this spectrum is Grade 5 severe Dhat Syndrome where the unfortunate sufferer is moribund and institutionalised within his neurosis, constantly preoccupied with thought of sexual negativity brought about by his own past behaviour. The literature, such as it is indeed, tends to lump Dhat Syndrome in with anxiety or, more usually, with depressive illness. To this writer it actually sounds more like an Obsessive Compulsive Disorder. In any case treatment, in severe cases, can be quite a challenge.
While this is not an area in which I can claim any expertise -- beyond trying to help these men and usually failing miserably, it does nonetheless occur to me that Dhat Syndrome may be a preventable disease. If, as seems to be the case, its geneses lies in the deeply embedded and erroneous notion that semen is sacrosanct to life and health, then surely it’s prevention equally lies in the purging of such misinformation at an early age. I would love to hear your thoughts on this. It is a very important subject if only because literally millions of lives are adversely affected by it every day.
Doctor Rynne www.doctorrynne.com
A Uniquely Indian Neurosis.
Dr Andrew Rynne.
Being is the business of Sexual Medicine, particularly Internet Sexual Medicine, I had long been aware of a syndrome unique to India and her sub-continent. And while being aware of it and my own obvious inability to do anything about it, I did not know that this culture bound malady actually had a name and was well described in the medical literature. One learns something new every day.
Dhat Syndrome is a sexual neurosis unique to India, Pakistan, Sri Lanka, Nepal and areas where the Hindu culture prevails or used to prevail. Some ancient teachings in that noble culture portray semen as a vital life giving force, as essential to life as blood itself. Variants of Dhat Syndrome do occur further east and in the orient, though here its prevalence is less obtrusive. In parts of India the prevalence of this very debilitating neurotic disorder may be as high as 30% which is very high indeed. This figure however needs further analysis.
The following symptoms would be classical for Dhat Syndrome:
(1) A morbid preoccupation with the loss of semen. This loss, or perceived loss, may arise from the imagined passage of semen in the urine. The loss of semen through spontaneous nocturnal emissions. And of course, perceived the most damaging of them all -- the loss of semen through masturbation.
(2) Sexual dysfunction or perceived dysfunction – erectile dysfunction and premature ejaculation.
(3) Unhappiness about the size or the shape of his penis. A conviction that his penis is shrinking.
(4) Fatigue, lassitude, tiredness, weakness, anxiety, depression and classically guilt about masturbation.
(5) Worry about future potency, fertility and an ability to father children.
(6) A preoccupation with pre-ejaculation discharge.
(7) An attitude of helplessness and dependency.
The overall incidence of Dhat Syndrome in India is between 10 and 30% which, as stated earlier, makes it almost endemic. This figure of course depends on how the researcher defines the condition. To reach that higher incidence of the disease, I suspect the statistician would need to utilise a very broad definition of Dhat Syndrome to include all young men with more than a passing concern about semen loss.
Then, although the literature does not say much about this, there are varying degrees or grades of Dhat Syndrome. Indeed it could well be the subject of a future Doctorate Degree in Medicine. This sexual neurosis could be graded from one to five in classic fashion. At one end of the spectrum are young men overly preoccupied with the ‘damage’ they are doing to themselves through masturbation. These men may be otherwise unscathed.
At the other end of this spectrum is Grade 5 severe Dhat Syndrome where the unfortunate sufferer is moribund and institutionalised within his neurosis, constantly preoccupied with thought of sexual negativity brought about by his own past behaviour. The literature, such as it is indeed, tends to lump Dhat Syndrome in with anxiety or, more usually, with depressive illness. To this writer it actually sounds more like an Obsessive Compulsive Disorder. In any case treatment, in severe cases, can be quite a challenge.
While this is not an area in which I can claim any expertise -- beyond trying to help these men and usually failing miserably, it does nonetheless occur to me that Dhat Syndrome may be a preventable disease. If, as seems to be the case, its geneses lies in the deeply embedded and erroneous notion that semen is sacrosanct to life and health, then surely it’s prevention equally lies in the purging of such misinformation at an early age. I would love to hear your thoughts on this. It is a very important subject if only because literally millions of lives are adversely affected by it every day.
Doctor Rynne www.doctorrynne.com
Monday, June 27, 2011
My Doctor Will Not Give me Testosterone Replacement. Why?
My Doctor Will Not Give me Testosterone Replacement. Why?
Dr Andrew Rynne.
Doctors around the world still remain sceptical about the value of testosterone replacement therapy (TRT) for certain men. They remain very sceptical against a backdrop of ever mounting good peer review clinical evidence showing that TRT has the capacity to greatly improve older men’s quality of life and indeed maybe even extend their life expectancy.
These doctor’s objections to TRT for older men may spring more from their emotions rather than from their intellect. Here are just some or their erroneous arguments and why I think they are wrong.
(1) The Women’s Health Initiative Study, published in 2002, showed that HRT was dangerous. This is a felonious argument on several fronts. First of all what this study actually showed was that Progesterone/Oestrogen combination increased the incidence of breast cancer in women by eight cases per annum per ten thousand women so treated. Secondly, it is nonsense to extrapolate from that which might be true for women in HRT to men taking Testosterone Replacement. At best that’s emotional, not scientific.
(2) Falling levels of testosterone is part of the ageing process and its consequences are natural. Here is another classic for you. Osteoarthritis of the hip is also part of the ageing process and its consequences are natural. But is anyone seriously suggesting that we should not treat osteo of the hip?
(3) Testosterone Replacement Therapy might raise the incidence of prostate cancer. First of all there is not a shred of clinical evidence that this is the case. And secondly, cancer of the prostate is NOT a disease of younger men with high levels of testosterone. It is a disease of older men with low levels of testosterone. If anything then, testosterone might be protective against prostate cancer but I am not making that point here.
(4) Testosterone might fan the flames of an existing, yet to be detected, prostate cancer. This fallacy comes from confused thinking. Because by removing all testosterone you can bring about a temporary remission in prostate cancer, therefore by adding testosterone you might make matters worse. This type of logic, if even logical it is, is called a corollary. Corollaries may work like a dream in religion or philosophy but have no place in science or in clinical medicine.
Doctors waffling on about the “dangers” of TRT are forever preaching to the rest of us about Peer Review and Evidence Based Medicine. They usually do this from the high moral ground of academia. And yet when it comes to ignoring their own advice, they seem to show very few qualms indeed.
This might be funny if it were not also quite tragic. We now know that TRT has many potential life enhancing and indeed life giving properties. The evidence for its value it treating the metabolic syndrome is emerging every day in new clinical trials. And yet so many of my colleagues are still with the dinosaurs.
Doctor Andrew Rynne www.doctorrynne.com
Dr Andrew Rynne.
Doctors around the world still remain sceptical about the value of testosterone replacement therapy (TRT) for certain men. They remain very sceptical against a backdrop of ever mounting good peer review clinical evidence showing that TRT has the capacity to greatly improve older men’s quality of life and indeed maybe even extend their life expectancy.
These doctor’s objections to TRT for older men may spring more from their emotions rather than from their intellect. Here are just some or their erroneous arguments and why I think they are wrong.
(1) The Women’s Health Initiative Study, published in 2002, showed that HRT was dangerous. This is a felonious argument on several fronts. First of all what this study actually showed was that Progesterone/Oestrogen combination increased the incidence of breast cancer in women by eight cases per annum per ten thousand women so treated. Secondly, it is nonsense to extrapolate from that which might be true for women in HRT to men taking Testosterone Replacement. At best that’s emotional, not scientific.
(2) Falling levels of testosterone is part of the ageing process and its consequences are natural. Here is another classic for you. Osteoarthritis of the hip is also part of the ageing process and its consequences are natural. But is anyone seriously suggesting that we should not treat osteo of the hip?
(3) Testosterone Replacement Therapy might raise the incidence of prostate cancer. First of all there is not a shred of clinical evidence that this is the case. And secondly, cancer of the prostate is NOT a disease of younger men with high levels of testosterone. It is a disease of older men with low levels of testosterone. If anything then, testosterone might be protective against prostate cancer but I am not making that point here.
(4) Testosterone might fan the flames of an existing, yet to be detected, prostate cancer. This fallacy comes from confused thinking. Because by removing all testosterone you can bring about a temporary remission in prostate cancer, therefore by adding testosterone you might make matters worse. This type of logic, if even logical it is, is called a corollary. Corollaries may work like a dream in religion or philosophy but have no place in science or in clinical medicine.
Doctors waffling on about the “dangers” of TRT are forever preaching to the rest of us about Peer Review and Evidence Based Medicine. They usually do this from the high moral ground of academia. And yet when it comes to ignoring their own advice, they seem to show very few qualms indeed.
This might be funny if it were not also quite tragic. We now know that TRT has many potential life enhancing and indeed life giving properties. The evidence for its value it treating the metabolic syndrome is emerging every day in new clinical trials. And yet so many of my colleagues are still with the dinosaurs.
Doctor Andrew Rynne www.doctorrynne.com
Testosterone Replacement Therapy
Testosterone Replacement Therapy. A Fresh Look Perhaps.
Andrew Rynne.
June 2011.
It has to be admitted, the word itself, “testosterone” does not usually evoke positive feelings or responses. In the popular press, the term testosterone is too often associated with reports about boy racers, reckless driving, male aggression, dodgy bodybuilding techniques, commercial dominance, sexual misbehaviour and cheating in competitive sports. All pretty negative stuff.
In the medical press the word “testosterone” does not fare much better. Mention of testosterone replacement therapy (TRT) to your average doctor is likely to elicit vague objections to do with increased cancer risks, it being not natural, it being unnecessary and other generally negative and ill-defined resistance to the suggestion. This may be a pitty.
No, let’s face it; testosterone replacement therapy was never going to be an easy sell. But are things changing? I for one very much hope that they are. I have been at this for almost ten years now, quietly promoting the notion of TRT. To summarily dismiss TRT as unnecessary, unnatural or even dangerous, might be to deny some older men a chance for a better quality of life and a chance for a reduced risk of contracting some of the less savoury side effects associated with the ageing process including premature death.
In the next five minutes, if you will allow me to, I hope to convince you to look afresh at TRT for older and for perhaps not so much older men and to consider recent research findings that cast this treatment in an entirely different and more positive light. Here are the bones of three recent studies that have been published this year alone:
(1) Low serum testosterone and increased mortality in men with coronary artery disease.
In a large study conducted through the Department of Cardiology, Royal Hallamshire Hospital in Sheffield on 930 consecutive men with proven coronary artery disease recruited between June 2000 and June 2002 and followed up for a mean of 6.9 years the Authors concluded:
In patients with coronary disease Testosterone deficiency is common and impacts significantly negatively on survival. Prospective trials of Testosterone replacement are needed to assess the effect of treatment on survival. (1)
(2) Effects of Testosterone Undecanoate (Nebido) on Cardiovascular Risk Factors and Arteriosclerosis in middle aged men with late onset Hypogonadism and Metabolic Syndrome.
This was a randomised double-blind placebo-controlled study on 50 men with mean age of 57 + or – 8 years who received 1,000 mg of Testosterone Undecanoate every 12 weeks or placebo.
Conclusion. Testosterone Undecanoate reduced fasting glucose, waist circumference, and improved surrogate markers of atherosclerosis in hypogonadal men with Metabolic Syndrome. Resumption and maintenance of T levels in the normal range of young adults determines a remarkable reduction in cardiovascular risk factors clustered in Metabolic Syndrome without significant haematological and prostate adverse events.
(3) Effects of Testosterone Replacement Therapy on Depressive Symptoms and Sexual Dysfunction in Hypogonadal men with Metabolic Syndrome.
This was a multi-centred, placebo controlled, study directed from the Department of Psychiatry, Leiden University Medical Centre in the Netherlands. In it 184 men suffering from Metabolic Syndrome and Hypogonadism were treated for thirty weeks with either Testosterone Undecanoate or placebo.
Conclusions. Testosterone Undecanoate administration may improve depressive symptoms, aging male symptoms and sexual dysfunction
in hypogonadal men with the Metabolic Syndrome. The beneficial effects of testosterone were most evident in men with the lowest baseline total testosterone levels.
* * *
Traditionally, doctors resistant to the notion that testosterone replacement therapy might be good for one, used to cite the lack of scientific evidence to support their negative views. This is no longer a tactic open to them. Here we have just a sample of some of the clinical studies showing benefit from TRT. Some of them may be small studies but they are peer review, published and conducted in line with strict scientific criteria. They are moreover ongoing. As time goes on you may expect to see further positive evidence for the beneficial effects of TRT.
What are the delivery systems now for testosterone replacement?
Two other points worth considering at this stage are testosterone delivery systems and the clinical criteria now applied when assessing a potential candidate for therapy:
Up to a few short years ago testosterone delivery systems were cumbersome, problematic, erratic and fraught. There were injections that tended to deliver the hormone in bursts that bore no relationship to the levels found in the physiological state. There were implants that were time consuming to insert under the skin and their use carried all the risks common to any minor surgical procedures. They also had a disconcerting tendency to be rejected. And then there were transdermal patches famous for giving rise to local skin reactions and dubious blood hormone levels.
All of these have now largely been replaced by either a transdermal gel – Testogel, Testim, Androderm etc or a long-acting deep intramuscular injection called Nebido and containing 1,000 mg of Testosterone Undecanoate in 4ml oily suspension. This is given every twelve weeks although in practise this is usually increased to be given once every ten weeks. Also, in practise, I find it easiest to prescribe the gel for the first two months before moving on to the intramuscular version, given at 0,6 and then every 10 weeks.
Do I need to run a battery of expensive and unreliable hormonal assays?
The second thing that has changed, or at least that is changing, is the criteria used to decide if a man needs or is likely to benefit from TRT. Heretofore the practise was to order up a battery of hormonal assays including free and total testosterone, sex hormone binding globulin and luteinising hormone to mention only a few. These tests are not just very expensive they are also notoriously unreliable; vary from hour to hour during the day and from laboratory to laboratory on split samples. In a study conducted in 2007 the authors concluded as follows:
Though laboratory assays can support a diagnosis of androgen deficiency in men, they
should not be used to exclude it. It is suggested that there needs to be greater reliance on the history and clinical features, together with careful evaluation of the symptomatology, and where necessary a therapeutic trial of androgen treatment given. (4)
This has made things a lot easier, not to mention a lot less expensive, for general practitioners considering TRT for certain patients. Today, doctors rely much less on hormone assay when deciding who and who should not be considered for testosterone supplementation. Nowadays I tend to take the pragmatic or empirical approach. If a sixty-three year old man comes to me complaining of mild depression and erectile dysfunction not fixed by Viagra then I would immediately think of TRT.
Or, if a seventy-two year old man attends with Type 2 diabetes and loss of libido, TRT will at the very least cross my mind such that I will discuss the ins and out of this suggestion with the client. The same holds true for the Metabolic Syndrome. Presented with an overweight, hypertensive, and hyperlipidemic man in his seventies, with a strong family history of coronary artery disease, I would, with very little hesitation, strongly consider TRT as a wise choice for him. In any of these situations, I would consider PSA as the only blood test necessary to do and even at that reluctantly.
As for gauging the clinical indications or efficacy of TRT, in the absence of blood androgen levels, we have the self-assessment tool known as the ADAM test. Here the client, not the doctor, scores himself against a series of graded questions to do mostly with his quality of life. If this score is low then perhaps TRT is worth considering. If after a few weeks on TRT his score remains low then perhaps discontinuation of TRT might be equally meritorious. This is pragmatic medicine. It can be as simple as that.
Does testosterone therapy cause prostate cancer?
There is no evidence that raised testosterone levels causes or increases the risk of prostate cancer. Prostate cancer is a disease of older men with reduces testosterone levels. It is not a disease of younger men with high testosterone levels. So, if anything, testosterone would appear to be protective of the prostate gland against malignancy. I am not making that case here though.
It has been observed in peer review study that by significantly reducing testosterone levels with the use of finasteride this can reduce the incidence of prostate cancer by some 25%. Does this not therefore strongly suggest that the increase of testosterone levels would have the opposite effect and increase the incidence of prostate cancer?
Yes indeed it does. But such a proposition is no more than a corollary and as with all corollaries it has to be accepted without any supporting evidence. You must accept it as “logical” and leave the field of clinical science and evidence based medicine behind you.
Corollaries work very nicely in religion and philosophy. God is good. If you don’t believe in God then clearly you do not believe in goodness. But do they work in medicine? I hardly think so. It is a tad annoying to see that the very people shuffling on the high moral ground of peer review science and baying for evidence based medicine only, can themselves so readily abandon such lofty principles when it suites them. There is a double standard at play here and it is not equitable.
Does testosterone therapy not risk accelerating the growth of a pre-existing yet to be detected prostate cancer?
This might be your Becher’s Brook when it comes to supporting TRT. But that’s all it is, a jump and like most jumps you can get over it. Castration, surgical or pharmaceutical, causes prostate cancer to regress albeit temperately. Therefore, watch the slight of hand here now, increased testosterone levels will or might fan the flames of an existing small and contained prostate cancer. Isn’t that only logical?
Indeed it is only logical. Note the imagery often used – fan the flames. Logical and emotional even. But is it scientific? Is it peer review and evidence based? No it is not. It is another corollary for which there is not one shred of clinical or scientific foundation to support. Indeed, what few studied there have been to date have all failed to demonstrate any correlation between raise testosterone levels and prostate cancer. And yet, when considering a man for TRT we still consider it necessary to apply that monkey-wrench of an instrument called PSA.
Summery. Debate and controversy continue to rage around the subject of testosterone replacement therapy. Clinical trials are ongoing and so far have delivered good news and even hint at an expanding potential range of disease processes related to ageing where TRT may be indicated.
Certainly, in the last ten years, we have moved a long was from thinking of TRT as a mere bedroom fodder, libido booster and adjunct to ED treatments. Evidence is slowly emerging to support the proposition that testosterone has a role to play in the reduction of dementias – senile and Alzheimer’s, the management of type two diabetes, hyperlipidemia, coronary artery disease, metabolic syndrome and osteoporosis.
The academic naysayers and detractors remain alive and well of course although the firmness of the high moral ground upon which they once stood maybe crumbling somewhat.
(1) Chris J Malkin,1 Peter J Pugh,1 Paul D Morris,1 Sonia Asif,1 T Hugh Jones,2,3
Kevin S Channer1
(2) Aversa A, Bruzziches R, Francomano D, Rosano G, Isidori AM, Lenzi A, and
men with late onset Hypogonadism and metabolic syndrome: Results from a 24-month, randomized, double-blind, placebo-controlled study. J Sex Med 2010;7:3495–3503.
(3) Giltay EJ, Tishova YA, Mskhalaya GJ, Gooren LJG, Saad F, and Kalinchenko
SY. Effects of testosterone supplementation on depressive symptoms and sexual dysfunction in hypogonadal men with the metabolic syndrome. J Sex Med 2010;7:2572–2582.
(4) The validity of androgen assays
Malcolm Carruthers,1 Tom R. Trinick,2 and Michael J. Wheeler3
1Centre for Men's Health, London, UK
2Department of Chemical Pathology, The Ulster Hospital, Belfast, UK
3Department of Chemical Pathology, St. Thomas' Hospital, London, UK
Correspondence: Malcolm Carruthers, Centre for Men's Health, 20/20 Harley Street, London W1G 9PH, UK. Tel: +44(0)2076368283. Fax: +44(0)2076368292.
Doctor Rynne www.docrorrynne.com
Andrew Rynne.
June 2011.
It has to be admitted, the word itself, “testosterone” does not usually evoke positive feelings or responses. In the popular press, the term testosterone is too often associated with reports about boy racers, reckless driving, male aggression, dodgy bodybuilding techniques, commercial dominance, sexual misbehaviour and cheating in competitive sports. All pretty negative stuff.
In the medical press the word “testosterone” does not fare much better. Mention of testosterone replacement therapy (TRT) to your average doctor is likely to elicit vague objections to do with increased cancer risks, it being not natural, it being unnecessary and other generally negative and ill-defined resistance to the suggestion. This may be a pitty.
No, let’s face it; testosterone replacement therapy was never going to be an easy sell. But are things changing? I for one very much hope that they are. I have been at this for almost ten years now, quietly promoting the notion of TRT. To summarily dismiss TRT as unnecessary, unnatural or even dangerous, might be to deny some older men a chance for a better quality of life and a chance for a reduced risk of contracting some of the less savoury side effects associated with the ageing process including premature death.
In the next five minutes, if you will allow me to, I hope to convince you to look afresh at TRT for older and for perhaps not so much older men and to consider recent research findings that cast this treatment in an entirely different and more positive light. Here are the bones of three recent studies that have been published this year alone:
(1) Low serum testosterone and increased mortality in men with coronary artery disease.
In a large study conducted through the Department of Cardiology, Royal Hallamshire Hospital in Sheffield on 930 consecutive men with proven coronary artery disease recruited between June 2000 and June 2002 and followed up for a mean of 6.9 years the Authors concluded:
In patients with coronary disease Testosterone deficiency is common and impacts significantly negatively on survival. Prospective trials of Testosterone replacement are needed to assess the effect of treatment on survival. (1)
(2) Effects of Testosterone Undecanoate (Nebido) on Cardiovascular Risk Factors and Arteriosclerosis in middle aged men with late onset Hypogonadism and Metabolic Syndrome.
This was a randomised double-blind placebo-controlled study on 50 men with mean age of 57 + or – 8 years who received 1,000 mg of Testosterone Undecanoate every 12 weeks or placebo.
Conclusion. Testosterone Undecanoate reduced fasting glucose, waist circumference, and improved surrogate markers of atherosclerosis in hypogonadal men with Metabolic Syndrome. Resumption and maintenance of T levels in the normal range of young adults determines a remarkable reduction in cardiovascular risk factors clustered in Metabolic Syndrome without significant haematological and prostate adverse events.
(3) Effects of Testosterone Replacement Therapy on Depressive Symptoms and Sexual Dysfunction in Hypogonadal men with Metabolic Syndrome.
This was a multi-centred, placebo controlled, study directed from the Department of Psychiatry, Leiden University Medical Centre in the Netherlands. In it 184 men suffering from Metabolic Syndrome and Hypogonadism were treated for thirty weeks with either Testosterone Undecanoate or placebo.
Conclusions. Testosterone Undecanoate administration may improve depressive symptoms, aging male symptoms and sexual dysfunction
in hypogonadal men with the Metabolic Syndrome. The beneficial effects of testosterone were most evident in men with the lowest baseline total testosterone levels.
* * *
Traditionally, doctors resistant to the notion that testosterone replacement therapy might be good for one, used to cite the lack of scientific evidence to support their negative views. This is no longer a tactic open to them. Here we have just a sample of some of the clinical studies showing benefit from TRT. Some of them may be small studies but they are peer review, published and conducted in line with strict scientific criteria. They are moreover ongoing. As time goes on you may expect to see further positive evidence for the beneficial effects of TRT.
What are the delivery systems now for testosterone replacement?
Two other points worth considering at this stage are testosterone delivery systems and the clinical criteria now applied when assessing a potential candidate for therapy:
Up to a few short years ago testosterone delivery systems were cumbersome, problematic, erratic and fraught. There were injections that tended to deliver the hormone in bursts that bore no relationship to the levels found in the physiological state. There were implants that were time consuming to insert under the skin and their use carried all the risks common to any minor surgical procedures. They also had a disconcerting tendency to be rejected. And then there were transdermal patches famous for giving rise to local skin reactions and dubious blood hormone levels.
All of these have now largely been replaced by either a transdermal gel – Testogel, Testim, Androderm etc or a long-acting deep intramuscular injection called Nebido and containing 1,000 mg of Testosterone Undecanoate in 4ml oily suspension. This is given every twelve weeks although in practise this is usually increased to be given once every ten weeks. Also, in practise, I find it easiest to prescribe the gel for the first two months before moving on to the intramuscular version, given at 0,6 and then every 10 weeks.
Do I need to run a battery of expensive and unreliable hormonal assays?
The second thing that has changed, or at least that is changing, is the criteria used to decide if a man needs or is likely to benefit from TRT. Heretofore the practise was to order up a battery of hormonal assays including free and total testosterone, sex hormone binding globulin and luteinising hormone to mention only a few. These tests are not just very expensive they are also notoriously unreliable; vary from hour to hour during the day and from laboratory to laboratory on split samples. In a study conducted in 2007 the authors concluded as follows:
Though laboratory assays can support a diagnosis of androgen deficiency in men, they
should not be used to exclude it. It is suggested that there needs to be greater reliance on the history and clinical features, together with careful evaluation of the symptomatology, and where necessary a therapeutic trial of androgen treatment given. (4)
This has made things a lot easier, not to mention a lot less expensive, for general practitioners considering TRT for certain patients. Today, doctors rely much less on hormone assay when deciding who and who should not be considered for testosterone supplementation. Nowadays I tend to take the pragmatic or empirical approach. If a sixty-three year old man comes to me complaining of mild depression and erectile dysfunction not fixed by Viagra then I would immediately think of TRT.
Or, if a seventy-two year old man attends with Type 2 diabetes and loss of libido, TRT will at the very least cross my mind such that I will discuss the ins and out of this suggestion with the client. The same holds true for the Metabolic Syndrome. Presented with an overweight, hypertensive, and hyperlipidemic man in his seventies, with a strong family history of coronary artery disease, I would, with very little hesitation, strongly consider TRT as a wise choice for him. In any of these situations, I would consider PSA as the only blood test necessary to do and even at that reluctantly.
As for gauging the clinical indications or efficacy of TRT, in the absence of blood androgen levels, we have the self-assessment tool known as the ADAM test. Here the client, not the doctor, scores himself against a series of graded questions to do mostly with his quality of life. If this score is low then perhaps TRT is worth considering. If after a few weeks on TRT his score remains low then perhaps discontinuation of TRT might be equally meritorious. This is pragmatic medicine. It can be as simple as that.
Does testosterone therapy cause prostate cancer?
There is no evidence that raised testosterone levels causes or increases the risk of prostate cancer. Prostate cancer is a disease of older men with reduces testosterone levels. It is not a disease of younger men with high testosterone levels. So, if anything, testosterone would appear to be protective of the prostate gland against malignancy. I am not making that case here though.
It has been observed in peer review study that by significantly reducing testosterone levels with the use of finasteride this can reduce the incidence of prostate cancer by some 25%. Does this not therefore strongly suggest that the increase of testosterone levels would have the opposite effect and increase the incidence of prostate cancer?
Yes indeed it does. But such a proposition is no more than a corollary and as with all corollaries it has to be accepted without any supporting evidence. You must accept it as “logical” and leave the field of clinical science and evidence based medicine behind you.
Corollaries work very nicely in religion and philosophy. God is good. If you don’t believe in God then clearly you do not believe in goodness. But do they work in medicine? I hardly think so. It is a tad annoying to see that the very people shuffling on the high moral ground of peer review science and baying for evidence based medicine only, can themselves so readily abandon such lofty principles when it suites them. There is a double standard at play here and it is not equitable.
Does testosterone therapy not risk accelerating the growth of a pre-existing yet to be detected prostate cancer?
This might be your Becher’s Brook when it comes to supporting TRT. But that’s all it is, a jump and like most jumps you can get over it. Castration, surgical or pharmaceutical, causes prostate cancer to regress albeit temperately. Therefore, watch the slight of hand here now, increased testosterone levels will or might fan the flames of an existing small and contained prostate cancer. Isn’t that only logical?
Indeed it is only logical. Note the imagery often used – fan the flames. Logical and emotional even. But is it scientific? Is it peer review and evidence based? No it is not. It is another corollary for which there is not one shred of clinical or scientific foundation to support. Indeed, what few studied there have been to date have all failed to demonstrate any correlation between raise testosterone levels and prostate cancer. And yet, when considering a man for TRT we still consider it necessary to apply that monkey-wrench of an instrument called PSA.
Summery. Debate and controversy continue to rage around the subject of testosterone replacement therapy. Clinical trials are ongoing and so far have delivered good news and even hint at an expanding potential range of disease processes related to ageing where TRT may be indicated.
Certainly, in the last ten years, we have moved a long was from thinking of TRT as a mere bedroom fodder, libido booster and adjunct to ED treatments. Evidence is slowly emerging to support the proposition that testosterone has a role to play in the reduction of dementias – senile and Alzheimer’s, the management of type two diabetes, hyperlipidemia, coronary artery disease, metabolic syndrome and osteoporosis.
The academic naysayers and detractors remain alive and well of course although the firmness of the high moral ground upon which they once stood maybe crumbling somewhat.
(1) Chris J Malkin,1 Peter J Pugh,1 Paul D Morris,1 Sonia Asif,1 T Hugh Jones,2,3
Kevin S Channer1
(2) Aversa A, Bruzziches R, Francomano D, Rosano G, Isidori AM, Lenzi A, and
men with late onset Hypogonadism and metabolic syndrome: Results from a 24-month, randomized, double-blind, placebo-controlled study. J Sex Med 2010;7:3495–3503.
(3) Giltay EJ, Tishova YA, Mskhalaya GJ, Gooren LJG, Saad F, and Kalinchenko
SY. Effects of testosterone supplementation on depressive symptoms and sexual dysfunction in hypogonadal men with the metabolic syndrome. J Sex Med 2010;7:2572–2582.
(4) The validity of androgen assays
Malcolm Carruthers,1 Tom R. Trinick,2 and Michael J. Wheeler3
1Centre for Men's Health, London, UK
2Department of Chemical Pathology, The Ulster Hospital, Belfast, UK
3Department of Chemical Pathology, St. Thomas' Hospital, London, UK
Correspondence: Malcolm Carruthers, Centre for Men's Health, 20/20 Harley Street, London W1G 9PH, UK. Tel: +44(0)2076368283. Fax: +44(0)2076368292.
Doctor Rynne www.docrorrynne.com
Understanding Doctors Hostility to Testosterone Replacement Therapy
Understanding Doctors Hostility to Testosterone Replacement Therapy.
Dr Andrew Rynne
Traditionally, doctors resistant to the notion that testosterone replacement therapy might be good for one, used to cite the lack of scientific evidence to support their negative views. This is no longer a tactic open to them. Hardly a day goes by now but that there is not some more good news about the value of TRT. Clinical trials are ongoing. As time goes on you may expect to see further positive evidence for the beneficial effects of TRT.
What are the delivery systems now for testosterone replacement?
Up to a few short years ago testosterone delivery systems were cumbersome, problematic, erratic and fraught. There were injections that tended to deliver the hormone in bursts that bore no relationship to the levels found in the physiological state. There were implants that were time consuming to insert under the skin and their use carried all the risks common to any minor surgical procedures. They also had a disconcerting tendency to be rejected. And then there were transdermal patches famous for giving rise to local skin reactions and dubious blood hormone levels.
All of these have now largely been replaced by either a transdermal gel – Testogel, Testim, Androderm etc or a long-acting deep intramuscular injection called Nebido and containing 1,000 mg of Testosterone Undecanoate in 4ml oily suspension. This is given every twelve weeks although in practise this is usually increased to be given once every ten weeks. Also, in practise, I find it easiest to prescribe the gel for the first two months before moving on to the intramuscular version, given at 0,6 and then every 10 weeks.
Expensive and unreliable hormonal assays are now a thing of the past.?
In a study conducted in 2007 the authors concluded as follows:
Though laboratory assays can support a diagnosis of androgen deficiency in men, they should not be used to exclude it. It is suggested that there needs to be greater reliance on the history and clinical features, together with careful evaluation of the symptomatology, and where necessary a therapeutic trial of androgen treatment given.
It has made things a lot easier, not to mention a lot less expensive, for general practitioners considering TRT for certain patients. Today, doctors rely much less on hormone assay when deciding who and who should not be considered for testosterone supplementation. Nowadays I tend to take the pragmatic or empirical approach. If a sixty-three year old man comes to me complaining of mild depression and erectile dysfunction not fixed by Viagra then I would immediately think of TRT.
It has made things a lot easier, not to mention a lot less expensive, for general practitioners considering TRT for certain patients. Today, doctors rely much less on hormone assay when deciding who and who should not be considered for testosterone supplementation. Nowadays I tend to take the pragmatic or empirical approach. If a sixty-three year old man comes to me complaining of mild depression and erectile dysfunction not fixed by Viagra then I would immediately think of TRT.
Or, if a seventy-two year old man attends with Type 2 diabetes and loss of libido, TRT will at the very least cross my mind such that I will discuss the ins and out of this suggestion with the client. The same holds true for the Metabolic Syndrome. Presented with an overweight, hypertensive, and hyperlipidemic man in his seventies, with a strong family history of coronary artery disease, I would, with very little hesitation, strongly consider TRT as a wise choice for him. In any of these situations, I would consider PSA as the only blood test necessary to do and even at that reluctantly.
As for gauging the clinical indications or efficacy of TRT, in the absence of blood androgen levels, we have the self-assessment tool known as the ADAM test. Here the client, not the doctor, scores himself against a series of graded questions to do mostly with his quality of life. If this score is low then perhaps TRT is worth considering. If after a few weeks on TRT his score remains low then perhaps discontinuation of TRT might be equally meritorious. This is pragmatic medicine. It can be as simple as that.
Does testosterone therapy cause prostate cancer?
There is no evidence that raised testosterone levels causes or increases the risk of prostate cancer. Prostate cancer is a disease of older men with reduces testosterone levels. It is not a disease of younger men with high testosterone levels. So, if anything, testosterone would appear to be protective of the prostate gland against malignancy. I am not making that case here though.
It has been observed in peer review study that by significantly reducing testosterone levels with the use of finasteride this can reduce the incidence of prostate cancer by some 25%. Does this not therefore strongly suggest that the increase of testosterone levels would have the opposite effect and increase the incidence of prostate cancer?
Yes indeed it does. But such a proposition is no more than a corollary and as with all corollaries it has to be accepted without any supporting evidence. You must accept it as “logical” and leave the field of clinical science and evidence based medicine behind you.
Corollaries work very nicely in religion and philosophy. God is good. If you don’t believe in God then clearly you do not believe in goodness. But do they work in medicine? I hardly think so. It is a tad annoying to see that the very people shuffling on the high moral ground of peer review science and baying for evidence based medicine only, can themselves so readily abandon such lofty principles when it suites them. There is a double standard at play here and it is not equitable.
Does testosterone therapy not risk accelerating the growth of a pre-existing yet to be detected prostate cancer?
This might be your Becher’s Brook when it comes to supporting TRT. But that’s all it is, a jump and like most jumps you can get over it. Castration, surgical or pharmaceutical, causes prostate cancer to regress albeit temperately. Therefore, watch the slight of hand here now, increased testosterone levels will or might fan the flames of an existing small and contained prostate cancer. Isn’t that only logical?
Indeed it is only logical. Note the imagery often used – fan the flames. Logical and emotional even. But is it scientific? Is it peer review and evidence based? No it is not. It is another corollary for which there is not one shred of clinical or scientific foundation to support. Indeed, what few studied there have been to date have all failed to demonstrate any correlation between raise testosterone levels and prostate cancer. And yet, when considering a man for TRT we still consider it necessary to apply that monkey-wrench of an instrument called PSA.
Summary.
Debate and controversy continue to rage around the subject of testosterone replacement therapy. Clinical trials are ongoing and so far have delivered good news and even hint at an expanding potential range of disease processes related to ageing where TRT may be indicated.
Certainly, in the last ten years, we have moved a long was from thinking of TRT as a mere bedroom fodder, libido booster and adjunct to ED treatments. Evidence is slowly emerging to support the proposition that testosterone has a role to play in the reduction of dementias – senile and Alzheimer’s, the management of type two diabetes, hyperlipidemia, coronary artery disease, metabolic syndrome and osteoporosis.
The academic naysayers and detractors remain alive and well of course although the firmness of the high moral ground upon which they once stood maybe crumbling somewhat.
Dr Andrew Rynne www.doctorrynne.com
Monday, May 23, 2011
Loss of Libido in Young Woman.
Loss of Libido in Young Woman.
What do you make of this? How would you advise? About a week ago, in my Allexpert.com slot, a young woman from South Africa wrote to me as follows:
“I have been thinking of asking for professional help for a while, because there seems to be a serious problem that I just can’t ignore. I am 32 years old, married for 7 years to a man two years my junior. Together we have four lovely children.
The problem started to appear after I started my third pregnancy and lately I just can’t handle it anymore. I do not want to have sex. I do not feel the need to. If I do it does not happen more than 2 or 3 times a month. Yesterday I realized that the mere thought of having sex disgusts me! I feel ashamed and insufficient to satisfy my husband who has been complaining about it recently. What’s the matter with me? I am a young vibrant woman. I take care of my appearance and I know that men like me, but something has stopped working properly. Please, please help me!”
First of all what sticks you about this questioner as odd, or as possibly the root cause of her problem? And secondly, what further information would you like to have before reaching a conclusion and offering some sound advice? Let’s deal with the second question first. When I hear of loss of libido in a woman the first thing I think of is clarity – what exactly does the questioner mean by loss of libido. The second thing that I think of is could some medications be causing this. I wrote to her therefore as follows seeking some clarity:
“Hi there Ruth, thanks for your question. When you say loss of libido do you mean loss of interest in all things sexual – no desire, no urge, on sex drive? Or is it a case that you do have these things but that you are not responding – you have so-called Female Sexual Arousal Defect?
I also need to know if you are on any form of birth control including the IUCD and if you were ever on any antidepressants?”
Her answers to these questions were revealing in their own way. No she was not on any form of BC, not now or ever and she was never on any antidepressants. As to the first part of my question; her problem was indeed a pure loss of libido and had nothing to do with response. While answering this Ruth also let it slip that she had a full time job!
This of course underlined and re-enforced my first impressions as to what exactly was going on here. Now we have a young woman aged 32 with four young children, obviously talented and well educated and holding down a full time job and not on any form of birth control! And she wonders where her libido has gone to! When I was first reading through her question I was thinking of all sorts of fancy footwork like hormone assay and possibly testosterone replacement therapy for women. But on more sober reflection the answer was far more pedestrian.
Four small children, under the age of seven, no matter how lovely they may be, is draining enough God knows. Now add onto that a full time, and I would guess a fairly onerous job and you are approaching human limitations. On top of that we have a young woman not on any form of family planning such that any sexual activity with her husband exposes her to the risk of further pregnancy and she is wondering where her libido has gone to!
Moral considerations aside, I think Ruth is going to have to give some serious consideration to possible a permanent form of family planning – vasectomy or tubal ligation or, less satisfactory, Marina Coil or implant. Once she has her fertility under some kind of control she should consider taking a break from her work and/or from her parenting duties. What Ruth may desperately need is a quiet week in the country somewhere. Then perhaps she will discover where her libido had vanished to.
What do you think? Please leave a comment.
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