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
Showing posts with label male. Show all posts
Showing posts with label male. Show all posts
Monday, June 27, 2011
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
Wrong Diagnosis
Shoehorning the Wrong Diagnosis.
Please don’t get me wrong. I have nothing against self-diagnosis and self-help when it comes to your health. Nor am I saying for one second that doctor knows best and patients should do what they are told to do by their doctor. On the contrary, I am all in favour of assertiveness in the doctor’s consulting room, all in favour of asking loads of questions and keeping the medics on their toes. As one myself I can assure you that doctors do NOT always know best or even know at all.
There are however exceptions to this rule, there are times to perhaps acknowledge that the old docs might actually know what they are talking about sometimes. A good example of this is in the management of erectile dysfunction in young men. There is something very peculiar about this common malady whereby the sufferer seems to want to hear certain explanations for his ED and reject treatment suggestions that somehow don’t seem to suite his predetermined prejudices. Nobody wants to be told that they have performance anxiety for example.
Take Jake from Saigon as a case in point. Jake, aged 36 came to me through my online medical consulting service. His complaint was erectile dysfunction his story typical yet quite extraordinary. Three years ago Jake bought some diet pills on the Internet and proceeded to take one a day. Of course this was foolish but if he had only left it at that it may not have been too bad. Worse was to come, much worse.
After taking these diet pills for a few days Jake noted, somewhat to his dismay, that he could no longer sustain an erection for more than a few minutes. Alarmed he went straight to his doctor and told him that diet pills had given him ED. Of course we don’t if the diet pills were in fact the cause of his ED but in Jake’s head that was the case and that was that. The doctor certainly did not agree that the diet pills had anything to do with it and offered Jake some Viagra to get him going again. Jake totally rejected this suggestion and, very annoyed he decided to consult Dr B and then Dr C. When Dr C also suggested Viagra Jake decided to see a specialist, an endocrinologist. Time to wheel in the Experts says Jake to himself.
At this stage Jake was beginning to think that maybe it was not the diet pills after all that were causing his ED and maybe the problem was a low testosterone. Armed with this new inspiration he asked the endocrinologist to run some hormone assays on him and low and behold didn’t the testosterone levels come back as “low”. Jake was at last vindicated. He knew what the problem was all along. The endocrinologist immediately ordered some Testosterone Replacement Therapy and everyone sat back and waited for Jake’s erections to return to their former magnificence.
Days ran into weeks and weeks ran into months and still the old erections would not last long enough to complete intercourse or to bring Jake’s long suffering wife to orgasm. Things were becoming desperate indeed. It was at this point that Jake was visited by yet another piece of inspiration. If his ED was not being caused by diet pills or a low testosterone level then the problem had to be a venous leek. There was something intrinsically wrong with Jake’s penis such that it would not hold the blood to sustain an erection. That had to be it. Time to see a surgeon says Jake to himself.
The Urologist obligingly went along with Jake’s suggestion of a venous leek and performed what’s called a Doppler test on his penis. And guess what? Yes you have got it, Jake was right again; he did have a venous leek! Surgery was organised to fix this defect, three month later and no improvement and Jake, at this stage a bit desperate it has to be admitted, was online availing of my $19.00. online consultation services. He presented himself as a victim of a series of stupid doctors who collectively could not fix his ED. He said very little about his not accepting the first doctor’s suggestion that his problem was performance anxiety erectile dysfunction. Nor did he acknowledge that the low testosterone theory and the venous leek theory were Jake’s inspiration and not the doctor’s.
If there is a there is a salutary lesson to be learned from this sad saga it is this: Common things are common and the commonest cause of erectile dysfunction in young is not diet pills, nor is it low testosterone levels, nor is it venous leek. No, the commonest cause of erectile difficulty in young men is performance anxiety and while that may be a bit pedestrian and lacking the exotic it is non-the-less true and very easy to fix. Jake would have done well to have listened to the first doctor he went. He could have saved himself a lot of pain.
What do you think? Please leave a comment.
Tuesday, March 22, 2011
Benign Prostatic Hyperplasia
Benign Prostatic Hyperplasia – the Classical Design Fault.
Lets face it, these days very very few patients indeed will consult their doctor without having first consulted Google, Yahoo, Bing and Wikipedia. Love it or hate it (and I suspect most of us are not overjoyed at the prospects of competing with computers) it is now the way of the modern world. It is here and here to stay.
Benign Prostatic Hyperplasia or sometimes, incorrectly, hypertrophy, is of course your classic. It has become a Global industry that stuffs the search engines for thousands of pages. Doctors, surgeons, hospitals, clinics, pharmaceutical and alternative enthusiasts all feed greedily from the bottomless trough that BPH has become. Any wonder then that the middle aged man, finally deciding to consult a real doctor for his dysuria, comes laden down with tonnes of cyber babble and internet rubbish.
The textbooks, but now of course the search engines; tell us that the incidence of BPH is about 50% in men over the age of 50 and more or less leave it at that. Doctors know of course that that is not the full story. In real life we know that the incidence of this pestilence increases with age such that by the age of 80 well over 80% of men will be significantly effected by it. Indeed all men will eventually fall foul to this design fault of nature. For that is what it is – a classical design fault. The urethra should never have been made to pass through a gland that is destined to enlarge with age. All men should be recalled at the age of forty and have this put right!
False dawns, in the form of “office procedures” for the surgical management of BPH continue to come and go. Transurethral Microwave Thermotherapy machines, like Electronic Voting machines, now lie gathering dust in back storeroom of many the teaching hospital. They are embarrassing monuments to the folly of rushing into unproven new technologies. Not only did they not work, they were also quite dangerous. Laser Turps, one suspects, may very well be heading in the same general direction. I will leave to others to inform us about its true efficacy when the dust eventually settles on this still controversial treatment.
If recently introduced minor surgical interventions for the management of BPH have been more gimmicks that genuine then the same can hardly be said about the pharmaceuticals. I refer particularly the alpha blockers of course. In the last twenty years, these medicines have allowed millions of middle aged men across the world, to get on with their lives in relative comfort and without the constant fear of the nightmare that acute urinary retention must be. They have also allowed men to at least postpone, perhaps indefinitely, the indignity in a TURPS procedure with its attending morbidities. Clearly I’m a big fan of the alpha blockers.
Not so however 5-alpha reductase inhibitor. Because Fenasteride has the ability to reduce prostate bulk by some 25% and so relieve some of the symptoms of BPH, this drug is now being pushed as a first line treatment for this benign condition. I believe that this is akin to the old proverbial sledge hammer approach to cracking a nut and I’ll tell you why.
Over the last five years or so, for my sins, I seem to have become more and more involved in the management of sexual dysfunction, not just erectile dysfunction but all sexual dysfunction in man and women. On the internet, hardly a week goes by that I am not being approached by yet another young man recently prescribed Propecia as a “treatment” for male pattern baldness. This drug has the capacity to obliterate their sexuality, not just for the time that they take the drug, but for all time. This vanity treatment can and does condemn many young men to a life sentence of sexual anhedonia, without feeling, desire or function, to otter misery and despair for which, as yet, we have no treatment. If you would like to know more about this you can share in their pain on www.propeciahelp.com
I believe that potentially toxic medicine like this must be reserved for the indications for which it was first introduced and that is in the management of advanced prostate cancer with metastases. Here, as we all know, it can be life-saving or at any rate life-prolonging. Using it to treat a benign condition like BPH is, in my view, at best questionable. Using it to treat a naturally occurring condition in men like male pattern baldness, is reckless in the extreme.
Finally, a word on tadalafil, the longer acting treatment for erectile dysfunction. Can I refer you to the October issue of the Journal of Urology 2008? Here is reported a study that found tadalafil to be as effective as the alpha blockers in relieving Lower Urinary Tract Symptoms of BPH. Since older men often suffer from both BPH and erectile dysfunction and since tadalafil has been clinically shown to relieve both, might not an argument be made for prescribing daily tadalafil for such men. Two birds with one stone perhaps? I think so.
Dr Andrew Rynne.
March 22nd 2011
Doctor Rynne is an expert on male and female sexual dysfunction. For more information please visit http://www.doctorrynne.com.
Sunday, February 20, 2011
Men with breasts. The enigma that is Gynecomastia
Men with breasts. The enigma that is Gynecomastia.
Definition: Gynecomastia may be simply defined as excessive breast tissue within the male breast. Note, the definition does not say “fatty tissue” within the male breast. Gynecomastia has nothing to do with being over weigh or fat. It is excessive breast tissue within the male breast itself. It can occur in thin men or fat men with equal distribution in men of all shapes and sizes and race.
Causes of Gynecomastia: Gynecomastia may be caused by the usual hormonal imbalance between estrogens and androgen associated with puberty. In the vast majority of cases this is transient but for no known reason, it can be persistent and account for up to 25% of all adult Gynecomastia.
Certain illicit drugs, most particularly marijuana and the anabolic steroids and medications used by body builders, can also give rise to male breasts which can be bilateral or, less often, unilateral -- on one side only.
Another cause of male breasts, particularly in older men, are raised estrogens levels brought about by increased aromatization of testosterone. This is particularly so where there is age or alcohol related liver damage.
Klinefelter’s disease is another rare cause of this condition, as is testicular cancer. However, in the vast majority of cases of Gynecomastia, the defect is idiopathic. ‘Idiopathic’ is doctor speak for not knowing what the cause is. But, rather than admit this, doctors prefer to lapse into a strange language.
Treatment of Gynecomastia. The treatment for male breasts is nothing short of a major internet industry. But be very careful here. This is one of those shark infested areas of cyberspace seething with charlatans and their cleverly written copy of false promises of hyped up miracle cures. The short answer is that there is no medicine, no hormonal gel, no herb, no exercises, no “system” of massage or any treatment that will make the slightest difference what-so-ever to reducing your “gyno” or reduce it by even a fraction of a millimetre.
The only proven way to permanently get rid of Gynecomastia is through a cosmetic surgery procedure to remove the excess breast tissue and underlying fat. Liposuction can be used to do some of this however it has to be done by a surgeon who has hundreds of these operations behind him or her and who knows exactly how much tissue needs to be excised. Do your research very carefully and don’t be afraid to ask lots of questions. Also ask for the names of some ex-patients who have had the operation at you chosen clinic. This will probably be refused unless they have the permission of some loyal clients, but I have seen lots of helpful blogger’s sites with very useful information on this difficult and sometimes embarrassing problem.
For more information please visit http://www.doctorrynne.com
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