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Understand when your testosterone needs a boost: replacement therapy may help restore lost vitality in the right instances and with the right lifestyle changes.

You're getting older. You've lost some muscle tone and some pep in your step, and your sex life isn't what it used to be.

Your thoughts turn to your testosterone level, and you think about testosterone replacement therapy (TRT) as a way to regain your youthful vigor. Trouble is, low testosterone may not be the only reason you're not feeling up to par.

So, ask your doctor about checking your testosterone, but know that TRT is an option only if your symptoms are from a testosterone shortfall and after you've addressed other potential causes, a Cleveland Clinic expert cautions. And, the therapy should be administered in conjunction with healthful lifestyle changes.

"Clearly, there has been a lot of marketing emphasis on testosterone as a cure-all," says Daniel Shoskes, MD, with Cleveland Clinic's Glickman Urological & Kidney Institute. "Make sure that if you're going on treatment, you're going on it for the right reasons."


Starting in their mid-40s, men generally begin to lose about 1-2 percent of their testosterone each year and may see a more significant decline after age 60. Although experts have yet to firmly establish a normal range of testosterone, levels less than 200 or 250 nanograms per deciliter (ng/dL) generally are considered low, while levels between 250 and 350 ng/dL may be considered borderline low.

Low testosterone, or hypogonadism, may cause a number of vague symptoms (see chart), but some of them also occur in men who are sedentary or otherwise in poor condition.

An array of factors has been tied to low testosterone and its symptoms. Long-term use of opiate pain relievers (such as hydrocodone and oxycodone) or corticosteroid drugs (prednisone is an example), as well as alcohol abuse, may contribute to reduced testosterone. Obesity, type 2 diabetes and obstructive sleep apnea also are associated with declines in testosterone, as are conditions such as chronic lung, liver and kidney disease.

If your medical history, symptom review, and physical exam warrant it, your doctor may recommend checking your testosterone with a basic blood test. Testosterone levels are highest in the morning and decline throughout the day, so testing must be done early in the morning. "Make sure that if you have your testosterone measured that it's done properly," Dr. Shoskes advises. "I see all the time people having a late-afternoon blood draw, which renders the number meaningless if it's low."

And, since testosterone levels fluctuate from day to day and can be affected by an acute illness, any low reading should be confirmed by at least one follow-up test given several days later, Dr. Shoskes says. Your doctor also should order tests to confirm whether the problem originates in the testicles or in the pituitary gland or hypothalamus, which prompt the testicles to generate testosterone.


In some cases, men with borderline-low testosterone have undergone treatment merely to boost their levels higher in the normal range, but Dr. Shoskes says no evidence supports the use of TRT in this manner.

"You should never treat a low value in isolation of symptoms," Dr. Shoskes says. "Clearly, the amount of testosterone circulating in the blood can be different for different people to produce symptoms. A lot of people have had a screening test as part of their annual physical and have a low number and absolutely no symptoms associated with it. I don't think there's any evidence that those people need treatment."

Guidelines recommend TRT for men with clinical symptoms and total testosterone levels below 350 ng/dL. Doctors may consider a three- to six-month trial of TRT for men with borderline-low levels and possible related symptoms and then re-evaluate them to gauge their progress, Dr. Shoskes says.

Before starting TRT, undergo a bone density scan, screening for prostate cancer and obstructive sleep apnea, and measurement of your hematocrit, the percentage of red blood cells in your blood. TRT is not recommended for men with prostate or breast cancer, a severely enlarged prostate, a hematocrit above 50, severe sleep apnea, those wanting to father children, or those with poorly controlled heart failure.

TRT is given as gels, patches or liquid applied daily to the skin, buccal formulations placed twice daily between the cheek and upper gums, pellets placed under the skin that release testosterone over four to six months, and injections given every 10-21 days. While injections produce fluctuating testosterone levels, the other preparations provide more consistent levels.

Testosterone treatment can boost your energy level and sex drive, help reduce depression, and lead to improvements in blood sugar, obesity, and muscle mass. However, its effects on erectile problems are less robust. "Probably the largest group of testosterone treatment failures are in those who have only erectile dysfunction and nothing else and are seeking testosterone to improve the quality of their erections," Dr. Shoskes says.


Follow up with your doctor three to six months after starting TRT and annually thereafter. Your physician may recommend bone-density tests and should check your hematocrit and perform a digital rectal exam and a prostate-specific antigen blood test to check for prostate cancer.

Most experts acknowledge that in properly selected patients TRT is safe. However, Dr. Shoskes cautions, "Even for men with truly low testosterone, we have poor data on the long-term effects. What men who are starting on therapy don't realize is that this is for life."

He emphasizes that before you start TRT, your doctor should rule out other potential causes of your hypogonadism and symptoms. Correcting these underlying problems may improve testosterone levels and your quality of life.

And even if you are on TRT, continue to optimize your health with a sensible diet, exercise, and, if necessary, medical management.

"If you exercise and you lose the fat and gain the muscle, you may well be able to come off testosterone and still feel well," Dr. Shoskes says. "But if all you're doing is taking testosterone to feel better and you do that instead of the other lifestyle changes, you're probably not helping yourself."


Low testosterone may cause one or more of these symptoms:

Sexual: Declines in sex drive; erectile problems, including fewer spontaneous erections

Body: Fatigue; loss of muscle and bone mass; increased body fat; swollen or tender breasts; hot flashes

Brain: Depression, impaired concentration

Sleep: Sleep disturbances (insomnia)


* Healthful lifestyle changes, including a low-fat diet and ample exercise, may improve your symptoms and well-being to the extent that you may not require testosterone replacement therapy (TRT).

* TRT treatment is not recommended for men with low testosterone and no symptoms.

* Low testosterone has been linked with obesity, type 2 diabetes, obstructive sleep apnea, alcohol abuse, acute illness, and chronic use of opiate and corticosteroid drugs, among other factors. Make sure these conditions have been addressed before deciding on TRT.

* Your testosterone should be measured first thing in the morning, when your testosterone is at its highest. Any low reading should be confirmed with a second blood test done several days later.

* Men on TRT must remain on the therapy permanently in order to maintain its benefits; however, data on the long-term safety of TRT are insufficient.

* After starting therapy, undergo periodic evaluations with your physician. Those exams should include screening for prostate cancer, blood tests of your hematocrit, and, possibly, bone-density scans.
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Title Annotation:SEXUAL HEALTH
Publication:Men's Health Advisor
Date:Mar 1, 2013
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