Testosterone: Myths & Facts

and I'm going to talk tonight about

testosterone

. Testosterone has been in the media quite a bit. There is a lot of information and misinformation about

testosterone

and I think it is a current topic. I like these things to be discreet, so if you have questions during raise your hand and stop me and ask questions. I think it's the best way for everyone to learn about the things I learned from your questions as well as everyone else in the audience, so feel free to ask questions. There will be a session afterwards as well, so in my practice there are four of us as a urologist at Holland Hospital and we all split things up, but we all have our little areas that we are interested in men's health, it is one of my concentrations and a big part of my practice is testosterone and testosterone replacement tonight I'm going to talk about some of the things that are important about testosterone and I can tell you that men with low testosterone levels really need to think about replacement of testosterone because the side effects of low testosterone levels can be significant and there is a great potential advantage in testosterone replacement therapy testosterone replacements important men with low testosterone levels who are symptomatic due to low testosterone levels I am a great replacement fan I think that I think that testosterone replacement can be very important and I think what is important is not only the replacement, but also the follow-up of patients who are on testosterone replacement treatment, that is very important and I think that what What's happening is that these somewhat fleeting testosterone replacement centers are popping up in malls, men's health clinics, that kind of thing and they're interested in getting you there, they're interested more in your wallet than you are. your health, so you have to be very careful when you're seeing someone for testosterone replacement, it's a tricky topic and I would.

I would caution people to be diligent about who they are seeing and who is treating them, so what are the issues in men's health in 2016? Maintaining diet and health is certainly important, and I think that's a big part of what I do when I talk to patients. about testosterone and testosterone replacement, as well as erectile dysfunction and other parts of my urology practice is health maintenance and dietary health, which is really important. Cardiovascular disease is a big topic and now we had a great cardiovascular center here that we've partnered with. with Holland Hospital bone and joint health is obviously important prostate cancer is a big problem twenty eight thousand men are going to die from prostate cancer this year and that's the same as 20 years ago so we have to do a better job of screening men and treating men benign prostate disease that is just difficulty urinating erectile dysfunction is important erectile dysfunction is a marker of vascular disease you have erectile dysfunction you are at increased risk of heart attack and stroke we know which, as a general statement, testosterone here and then is the kind of The business of results of medicine versus fee for service.

You know, we've traditionally been a fee-for-service health care system. When you come to see me, I do things for you and they pay me to do them. I don't necessarily get paid to make you or keep you healthy and now the results are more important to me. Now they reimburse me and incentivize me based on results and that's a big issue, so what's the problem with testosterone? Testosterone has direct and indirect effects on all organ systems in the male body. Testosterone can interact with all cells in the body. Hypogonadism, which is a low level of testosterone, is a crucial factor in patients with chronic diseases, so when I talk about chronic diseases, I mean diabetes, congestive heart failure, hypertension, prostate cancer, all of that. . those chronic disease states that are being managed, testosterone plays a role in changing demographics and what I mean by that is 15,000 people turn 65 in this country every day, so we're seeing this growing population of men as they get older. and what I've seen in 22 years of practice is that men, as they get older, they don't sit in front of the TV and put their feet up, they want to interact with people, they want to be active, they want to live the life they want. to do things, they want to work, they want to be intimate, they want to maintain relationships and that is an important aspect of things, so we are seeing more and more patients who are over 65 years old and perhaps are to a greater degree or more susceptible to low testosterone levels, we know. that five million men in the United States are affected by low levels of testosterone that that number is incorrect, it is much more than five million, so now that we are talking about the process of this disease and what are the symptoms of low levels of testosterone, that number is going to increase increase significantly there are huge potential benefits of the treatment what are the risks of testosterone replacement is an area that has generated a lot of controversy there was an article in the journal of the American Medical Association that came out that attracted a lot of interest and talked about the increased risks of heart attack and stroke and men on testosterone replacement therapy, but if you dig deeper into the statistics, the statistics will actually tell you that just the thirty opposing medical societies petitioned the Journal of the American Medical Association to retract that article that has not been done. but again, the risks are significant, it's something we need to talk about and discuss when I see patients with low testosterone and I talk about treatment, so four to five million people have low testosterone, men were specifically what we're talking about and again this.

The number is low, but only 5% of effective men are currently being treated and that is not a good thing tonight. What I want to talk about is the regulation and physiology of testosterone secretion. Where does testosterone come from? That's something important to understand testosterone deficiency in chronic disease states and again diabetes high blood pressure congestive heart failure prostate cancer those diseases that are managed regularly let's talk about testosterone and metabolic syndrome testosterone replacement and prostate cancer testosterone replacement in aging male sexual function and I'm also going to touch on some replacement options, that's how we get testosterone and how it's produced in our body, it's produced in a couple of different places, but ultimately, cholesterol from the which comes from testosterone and cholesterol becomes this and this and this and this and this and there we get testosterone this is a cascade of enzymes that does this and then with this enzyme we get the female hormone so all men have some female hormone all Women have some male hormone and both levels are important for their health too, but that's the science of things we know that testosterone is the main primary circulating androgen androgen means it's a steroid that makes us strong it's supportive it keeps us healthy strengthens our muscles and strengthens our bones and strengthens our brain and other parts of our body in a nutshell this is the basic secretor this comes from the hypothalamus this topic this compound here called can addict rope and releasing hormone that creates the secretion of luteinizing hormone the pituitary the lady cells are in the testicles and those are the ones that stimulate the production of testosterone this is how it is produced it is simple the adrenal cortex the adrenal gland is the small gland above the kidneys we all have adrenal glands and no, those they are important you really can't live without your adrenal glands or you can live with difficulty without your adrenal glands 5% of our androgens come from the adrenal glands we know that testosterone secretion is pulsatile we have a kind of explosion in the morning and there is a little burst in the late morning as well and that again is some support, the highest concentrations in the morning and one thing we know when we measure testosterone in the bloodstream, all the testosterone that we measure is not the same, so we have We have to know what we are measuring and interpreting. get things right this is just another kind of messy slide talking about how things work the hypothalamus secretes GnRH which goes to the pituitary which secretes luteinizing hormone which goes to the testes and the Ladak cells then secrete testosterone that's the network that's the basic science lesson Again, this is another one of the basic science things, the basic science of this sounds complicated, but it's actually pretty simple when you dig into it, so what happens is that testosterone circulates in our bloodstream and it goes to many different cells in our body and all of those cells have these receptors, these specific receptors for testosterone, testosterone can attach to this receptor which then gets incorporated into this cell and modulates all of this stuff that happens in the cells. from the bones to the muscles of the brain and the blood vessels throughout our body, testosterone has significant effects and, again, it is a somewhat complicated process, but simplistically speaking, testosterone reaches the cells of our body with relative ease and it has effects on most cells, so what?

They are the direct effects of testosterone muscle mass, it improves the formation of muscle and bone mass, it helps us produce sperm for reproduction, sexual function, also testosterone is converted into something called dihydrotestosterone, which is really very important, since which creates facial and body hair that, to a certain extent, can create. scalp hair loss and baldness, although that is different in the way testosterone is converted to DHT from one patient to the next, it can cause certain types of prostate growth and function and can also promote erectile function. It can also cause some acne, ultimately testosterone. again it can become the female estrogen, estradiol-like component, which is important for bone health, for high-density lipoproteins, which is healthy cholesterol, which can have an impact on atherosclerosis and estradiol also has some major problems with cognition and verbal fluency, for which we can thank women.

As men we can thank women for their hormones that make us smarter and more fluid and also prevents dementia and Alzheimer's and some aspects, although that is a little more complicated, so the testicles produce testosterone after all these complicated things in the brain. and it's sitting there in our body, we know that there is bound and free testosterone. Bound testosterone doesn't work, it's attached to other compounds that prevent it from doing the things it does. Free testosterone is what acts, it is free testosterone. that we can measure unfortunately assays to measure free testosterone are difficult, inexpensive and not always done correctly so most of us don't like to look at free testosterone in certain academic centers we can do it but here I don't look . in free testosterone very often, if I want to look at it, it's more of a calculated number than an actually measured number.

Sex hormone binding globulin and albumin bind to testosterone when it is bound to sex hormone binding globulin, most of the time testosterone is absolutely unusable. By the body, the albumin is a little less bound, what we call bioavailable testosterone, which is what works, it is the free plus the bound albumin and again the sex hormone binding globulin portion can prevent the testosterone from working properly, so what when I look at someone the first time and I'll go into that I look at total testosterone just a baseline total testosterone first thing in the morning fasting during midnight the night before that's the first screening test I do, but I don't know.

It doesn't spread to everyone. I know everyone who walks through my door. I'm not asking for testosterone. I want to know if they have symptoms too and symptoms are an important part of the whole diagnosis, so this seems like it again. in testosterone, only 2% of our testosterone is free and actively available, 60 percent is very tightly, we call it covalently bound and it cannot be used by the body, it cannot be incorporated into those cells, it cannot bind to those receptors and are absorbed by the cells and are churned and used 38% is bound to albumin in certain patients, the concentration of albumin changes, goes up and down and can alter the amount of free testosterone or testosterone that is available for the body to function correctly, so measure testosterone levels, this is what you just asked abouttime is important and I think time is important from a consistency standpoint, so what the American Neurological Association states, the American Andrological Association, which is kind of the Aging Association, the Endocrine Society, we all have I came up with these guidelines, so when I see someone who I think has low testosterone, I'm pretty adamant about making sure I measure them first thing in the morning, so before 9 o'clock, 7 to 9 o'clock. the morning and on an empty stomach. from midnight the night before, so timing is important and total testosterone can again be affected by this sex hormone binding globulin again.

There are these assays that can measure free testosterone and total testosterone, but not everyone has those assays available, so we have To have some kind of standard, do we go by the Endocrine Society guidelines? Those are the ones we really look at, although the American Neurological Association recently put out their guidelines as well, so when someone comes to my office who has who I believe. like low testosterone levels or they think we have reached low testosterone levels in some aspect, this is relatively new Questionnaire that looks at screening men for low testosterone levels, it's called male antigen deficiency and aging questionnaire and this is a series of 10 10 questions that patients are answering us.

These quizzes are fine. You know, one of the things we like is objective evidence, so if I were seeing someone with high blood pressure, I can measure their blood pressure and I'll measure it and that will give me a discrete objective number. It's a little different with something like low testosterone. these symptoms and people interpret these symptoms differently, in addition, some patients have difficulties with these, some patients because the print may be too small, they may have some cognitive problems that they cannot understand, so we cannot fully trust in this. and I do in a sense, but not in all patients, most of what I get from a symptom standpoint is my direct questions with patients, so I don't even like nurses coming in and talking with patients before seeing them because I like it. asking the patient and listening to their first answers, that's the most sensitive way I can get an idea of ​​whether I think they're really suffering from hypogonadal symptoms, so they're fine, but they're not perfect, and the blood tests are fine, but they are not perfect.

You're not perfect either, if you look at most tests, if you get a total testosterone at Holland Hospital, they'll tell you the normal range is about one hundred and eighty to about 750. I don't use that, none. Of us who replace testosterone use that number, so it is for its own legal medical purposes, but I don't normally use it, so let's look at the types and causes of low testosterone. Type number one is called primary hypogonadism and that's testicular insufficiency, for some reason those Leydig cells in the testicles don't make testosterone and that can be due to infection, injury, surgery, blood flow, a variety of things. different, but that is called primary hypogonadism.

The secondary one is due to a dysfunction of the hypothalamus or the pituitary gland. that GnRH, that first signal that is secreted by the hypothalamus, if it is not working properly, then it will not tell the pituitary to tell the testicles to produce testosterone, in the same way, if there is pituitary dysfunction, if luteinizing hormone is not secreted correctly, that will not work. synchronize with the signal from the testicles and that is called secondary hypogonadism and that is why with a little patience I will look at your pituitary gland more specifically and occasionally I will find pituitary diseases and pituitary tumors and other things that are happening in the pituitary gland that need to be Most frequently evaluated there is something like a combined primary and secondary deficiency.

There is also some unusual congenital meaning that you are born with problems and symptoms and abnormalities called Calman syndrome which can cause low testosterone levels. People are born with it. It's a little harder to distinguish, so what does testosterone do? It provides male sexual function and one of the most sensitive indicators of low testosterone when I talk to patients is their libido, their interest in intimacy. Men have a strong libido and it lasts for a while. Long time men coming to me and telling me they are not interested in intimacy is a red flag that they have low anabolic testosterone, anything that is anabolic means getting stronger, building your muscles, your brain, your bones , your blood vessels, things like that.

It basically affects hematology, but that means that testosterone will interact with the bone marrow to form blood vessels. That's why cyclists in the Tour de France abused testosterone in the past, it increases their hemoglobin, their oxygen carrying capacity and the hemoglobin is normal at about 17, 16 or 17 they will get their hemoglobin up to 20 and 21 and 22 so they can carry more oxygen, it's against the rules and can have some detrimental effects like a stroke, so it's bad that bone metabolism is a huge, flourishing area. from testosterone research that looks at bone metabolism because what happens as we age as our bones weaken and what's happening in the population right now is that people like to stay active and bone fractures Hip in people as they age can have a major problem in their livelihood. and its ability to function affects mood and cognitive effects mood and cognitive effects are very important when it comes to testosterone, that does not mean depression bad mood and depressed mood are important, which is More importantly, I think some of these cognitive effects are our ability to do the crossword puzzle. puzzles and and and function and read books that we want to read and maintain our brain in some sense, there are definite insulin and cardiovascular effects that are moderated by testosterone, which is what we're talking about when we talk about insulin and cardiovascular effects.

We're talking about diabetes, heart attacks and strokes, which are a very big part of things. Testosterone actually has a vasodilator effect, meaning it dilates blood vessels, so one of the problems with heart attacks and strokes is that you lose blood flow. Stroke is a little different: you can have different types of stroke, such as lack of blood flow or bleeding, but you can counteract the narrowing of blood vessels, which normally occurs as we age, and atherosclerosis and narrowing. of those blood vessels that can be compensated by testosterone. and there is a definite vasodilator effect, blood vessels become larger and flow better, blood flows better with testosterone replacement in men who have low testosterone levels.

Yes, the question is, you don't need to have low testosterone or low blood flow. There is no low blood flow. be a multifactorial thing and caused by many different things, testosterone can be part of that, yes the question is does low blood flow cause low testosterone, in theory it could be if blood flows to the testicles and you don't get the flow blood that you need, so yes. We could see the anabolic effects for a second. We know that testosterone increases lean body mass, that is, muscles and bones. We know that testosterone also decreases fat. We know that men have a tendency to gain weight here in truncal obesity.

Women are kind of button thighs. I'll see men who have that kind of appearance that's characteristic of that trunk obesity and that can be a sign of low testosterone levels. We also know that testosterone is involved with this evil here. Mesenchymal stem cell differentiation basically what that means is that that. It can intervene and interact with cells in their nucleus, which means that there are cells in our body that can become a lot of different things, really important cells in our body and testosterone can have a very positive effect on those cells and that may be related in some way.

With respect to certain types of cognitive deficits like dementia and Alzheimer's disease, the hematological effects that I talked about before and again, testosterone can interact with the bone marrow to create healthy blood cells like hemoglobin, what we see is this abnormal elevation of blood cells, especially when we are replacing testosterone with an injection every two weeks, so we have to be careful with the men I see and who I am treating with testosterone injections. I want to be careful and follow his hemoglobin level because occasionally I see some elevated levels that need things to be tweaked a little.

Effects of bone metabolism. There are multiple pathways with testosterone that affect bone mass and bone health and again, as we get older and active, we are at greater risk for problems like hip fractures. and and that can create major problems. We know that estradiol inhibits bone resorption, so estradiol comes from testosterone. You have to have enough testosterone to have enough estradiol and if they don't affect bone resorption, that just means there is bone. are healthier overall, there have been a couple of studies that have looked at estradiol levels in men who have had hip fractures, and generally speaking, there seems to be some lack of estradiol in those men again, which is that the risk hip fracture and testosterone levels are very high.

It is important that you interact with orthopedic surgeons and talk to orthopedic surgeons who are replacing hips and people in their 80s and 90s. We want to make sure they have good testosterone levels. I think that may be an AB for them to heal properly. after hip replacement surgery again, mood and cognition I think is really an important issue. We know that testosterone improves the positive aspects of mood and reduces the negative ones. The effects on Frank's depression are unclear. There is some active research being done at the University of Michigan. in depression very careful studies looking at depression and testosterone replacement again cognition is another important thing and helps us live our lives and do the things we want to do as we get older to your question does a little testosterone have an effect vasodilator is like a calcium channel blocker we use calcium channel blockers and patients with hypertension the blood vessels become too tight we put a calcium channel blocker on them we open those blood vessels we lower blood pressure well, testosterone has the same effect to some extent and some more significant research is While we're talking about this, we also know that there is an inverse correlation between testosterone levels and cardiovascular risk, so as testosterone levels decrease, the risk of heart attack and accident cerebrovascular increases, we also know, as I said before, that there is a similar inverse relationship between the levels. of testosterone and visceral fat, that is, truncal obesity, testosterone levels go down, visceral fat increases, larger population studies are needed because both this cardiovascular risk and this visceral fat are affected by so many different things that we need these more big. population-based studies to figure things out and figure out what's more important and what's less important, there appears to be a growing body of evidence supporting the notion that men with lower testosterone levels have a more significant risk of disease cardiovascular that has been a A recent article from MD Anderson in Texas was very well dated and supports that there are very few articles that suggest the opposite of articles in general, as if we know what happens with testosterone deficiency and chronic disease states . are common diabetes is a chronic disease the state hypertension is a chronic disease the state congestive heart failure is a chronic disease the state certain types of lung dysfunction prostate cancer is a chronic disease the state all of these are important when treating of testosterone these are our problems that we have come into contact with so we know that in chronic disease states testosterone can have a centrally mediated effect so these disease states will affect our brain which leads to stress and malnutrition, the use of medications for pain, infections and things like that. and all of these can have direct effects on testosterone function and production.What about HIV and AIDS?

We don't see much HIV and AIDS here now, but it's a big issue elsewhere. When you get to the larger cities, we know that 50% of HIV/AIDS patients have decreased testosterone levels, the reason I mention this is that HIV/AIDS is no different from other types of chronic diseases. Now you know, we used to think of HIV/AIDS as something that was relegated to a certain segment of the population and that was a deadly disease, it's actually not a controlled disease now, it's a chronic disease and it may be that it can mimic and in some ways the chronic disease of diabetes, there have been some studies that analyzed are very similar in many aspects and what we know is that patients with these chronic diseases are more likely to have low levels of testosterone, which has effects significant impacts on their livelihood, their ability to receive treatment for these chronic diseases, and ultimately their health.

Mortality and they are like they are dying. Malignancy is another chronic disease. 50% of men treated for malignancies have low testosterone levels, so when we talk about men with lung cancer, prostate cancer, pancreatic cancer or colon cancer, I think it's really important that we look at their testosterone levels. You know, we used to say that if men have prostate cancer they can't have testosterone replacement, it's a contraindication and we even say that now with many testosterone medications, but I have a There are a significant number of men who have prostate cancer who have I'm giving testosterone and they're doing well, not all of them, but a significant portion of them, so I think men with malignancies are really important and I've talked to my hematology and oncology colleagues about this.

It's really important that we look at these men and talk about treating them. We don't just focus on your cancers, but your overall health and part of that is your testosterone levels. Again, cardiovascular diseases. There was a study done in the Netherlands, they looked at low testosterone levels and Horta catharsis chlorosis, so the aorta is that large blood vessel that comes out of the heart and supplies blood to the rest of our body, this study showed definitely that men were much more likely to atherosclerosis or narrowing of that important blood vessel if their testosterone was lower.

A similar study called the carotid artery study showed that narrowing of the carotid artery was much more common in men with lower testosterone levels a narrowing of the carotid artery means you are at higher risk of stroke, we know that testosterone replacement therapy leads to better exercise tolerance and healthier blood vessels testosterone replacement therapy improves cholesterol good and reduces bad cholesterol. Testosterone replacement therapy can be cardioprotective, it can prevent you from having a heart attack or stroke, and again, I think heart attacks and strokes are multifactorial. There are many things that can influence it, although yes, well, the problem with narrowing of the carotid artery you may not have symptoms until you have a stroke and that is why regular health maintenance and maintenance you being healthy is important, you know again in the past when I talked about how our healthcare system works, it's important now that we're looking at the results, so you as a patient, if I'm your primary care doctor, my job is much more important for me to keep you healthy because I will be paid to keep you healthy, so by looking at your carotid arteries and by looking at your other blood vessels, you may not have any symptoms of carotid artery narrowing until you have a stroke, so it is important to observe patients. in general, and maybe there are, but they can be quite subtle, yes, there are a lot of little things, but there are also a lot of symptoms that you could have, but again, it's one of those things that your primary care doctor will look at closely. nearby and determine if you are at increased risk for a heart attack or stroke.

So what about metabolic syndrome? Metabolic syndrome is something we are seeing much more frequently in these cases. days and what metabolic syndrome is is a combination of obesity, increased cholesterol and sugar, loss of good cholesterol, high blood pressure and low testosterone levels, so 25 years ago metabolic syndrome did not exist, now there are many patients that are defined with this metabolic syndrome and I see a lot of patients in my practice so I think I will have that syndrome and those are patients that I talked to about low testosterone, we know that based on this study on male aging of Massachusetts, there is an increased risk of metabolic syndrome in men with low testosterone, so it's not the other way around, it's not that you have low testosterone and you have metabolic syndrome.

In Finland, men with low testosterone were at higher risk of this metabolic syndrome or diabetes, so multiple studies have documented benefits. of testosterone replacement therapy in this patient population, what about prostate cancer? So prostate cancer is something that we as urologists see all the time and it's really important to us, and this is a really important statement. This is dr. collie Carson of Duke University, there is currently no evidence that testosterone replacement therapy initiates prostate cancer or stimulates a subclinical malignancy to become clinically evident, so what this means is that if you have low levels of testosterone and I treat you, you will not have prostate cancer. what that means and it means I can give you testosterone replacement even if you have prostate cancer whether it's been treated or not and that doesn't happen in everyone so what's happening today with prostate cancer is that We understand that we overdiagnose and overtreat whenever possible.

Prostate cancer is so I have a lot of men who have been diagnosed with prostate cancer who haven't required any treatment, we're just following them. It's called active surveillance. Men with that diagnosis who have low testosterone levels. It is reasonable to treat them. I follow them carefully, but it is reasonable to treat them. What about prostate size and PSA? We know that as the size of the prostate increases it would be erotic. Lee makes it harder for us to urinate and that is a reasonable statement. We also know it. that testosterone can affect PSA, prostate-specific antigen, which is the blood test we do to help us detect prostate cancer.

We know that testosterone replacement therapy could increase prostate size, but I would tell people even with larger prostates, that they have more, that they have more. prone to urinary symptoms it is fine to put him on testosterone replacement therapy and just monitor things, it is rare that you will see an exacerbation of urinary problems in men with larger prostates who are on testosterone replacement therapy, we also need to make sure to follow the PSAs and the patients on testosterone replacement therapy, so this was a small study that was done there were ten patients who had their prostate removed for prostate cancer they underwent testosterone replacement therapy there was no change in their PSA and there was a significant increase in their quality of life and that's important again.

I think there is a myth about prostate cancer and testosterone replacement therapy. It's interesting if you look back at the history of prostate cancer, there was a doctor in Chicago in the 1930s who was a Nobel Prize candidate on several occasions who showed that we could take testosterone away from men and they thought that would cure cancer. prostate. We know that doesn't happen today, but now that the pendulum is swinging in the opposite direction, we are understanding that even if you have prostate cancer, we can safely replace your testosterone, so after prostate removal we know that we follow patients very carefully with PSA and regular rectal exams.

We know that we treat testosterone replacement therapy in these men with the least amount of medication than that. improves your symptoms that treats your symptoms and we know that these patients must have symptoms of low testosterone, so just because your testosterone is low if you have no symptoms that does not require treatment, but we need 5000 prostate cancer patients followed for three to five years to accurately answer all these questions. Fortunately, there is a large study going on at the University of Michigan that is pooling all of the urology practices in the state of Michigan and we are combining all of our patients, so we are getting this data.

As we talk and we'll have more confirmation dates on this, I would still tell you that I have no qualms about treating patients with a history of prostate cancer with testosterone replacement therapy, so in summary, most epidemiological studies suggest that There is no association between das drone levels and However, I will tell you that I believe that at the time of diagnosis in hospitalized patients, if their testosterone is abnormally low, they are at increased risk of prostate cancer and most of us believe that today Today it has to do with how prostate cancer works. it grows and develops and if it can grow and develop without testosterone around, it is probably a more virulent disease.

So what happens to aging men? 5 million men in the United States have hypergonadal or low testosterone levels, but only five percent again receive replacement therapy. I know that from my point of view and from all of our points of view in urology, we are much more attentive to identifying these patients with low testosterone and really focusing on treating them because, again, I think their quality of life can increase significantly. We know that testosterone secretion decreases. with age, the short term consequences are a lot of lack of interest in insects and a depressed mood like depression, probably the wrong word here, the longer term consequences, bone loss, muscle mass, muscle mass problems , cardiovascular risks and again there is this baby boomer population that is really a burgeoning part of the population that we are seeing today and our practice volumes are increasing immensely so there have been a couple of good studies that have looked at the question : can testosterone replacement therapy reverse bone loss, so there have been a couple of interesting studies that have measured bone loss with certain types of x-rays and these have been very sensitive x-rays. bone quality and patients with low testosterone levels and these men have been under very strict control. testosterone replacement therapy regimen and they have been re-imaged and the quality of their bones according to these imaging studies has improved significantly, which just means they have healthier bones, less risk of fracture and one of the studies performed mainly in cancer patients we have a higher risk of bone loss due to the effects of chemotherapy, so it is a good question, the question is: would the same happen with arthritis?

Nobody knows. Logically, I would tell you that certain types of arthritic changes can occur. decreased with testosterone replacement therapy in patients with high pokken adil levels, but those studies haven't been done there, there's a big push on that simply because of the number of people who have had surgery for different types of arthritic problems in joints and in their backs and there is a study going on at UCLA and in Los Angeles looking at patients who have had back surgery for chronic back pain and have low testosterone levels and there are ways we can see better results in these back surgery patients, that is a good question.

The question is why PCPs are more attentive to testosterone screening. I will defend them a little and tell them that I think they are as busy as they can be. Their plates are stacked. My preference would be. They talk to patients about low testosterone levels and they send them to me, that would be the way to go and not from a monetary standpoint because I'm as busy as I can be right now, but I'm focusing on this and I think I can. Better evaluate and treat these patients. I think they will focus on the things that are most crucial: your diabetes, your blood pressure, and your cholesterol, but they have so many things to look at on a daily basis with each patient that there is a point.

Over time, when things become somewhat limited, and I think that's the case as well, if you look at the Affordable Care Act and what it's doing, you know I would defend the Affordable Care Act.in some sense because I think the push there is to look at the results, so right now no one looks at my results at all, if you come to me and I operate on you there, I get paid to operate on you, no one looks at my results, that's changing, primary care doctors are now being more qualified in their outcomes are more strict, you know, over and over again, what I think is really important is that you have to be your own advocate and push the buttons and say: I need this, Unfortunately the health system is what is happening. these big changes right now I think a lot of the changes are good, some of the changes are not good, but keeping patients healthier is the goal, should be the goal of fee-for-service medicine, which is what we had. forever didn't really matter, it did, it didn't focus on keeping patients healthy.

I think that is changing, yes, again, I think the PCP is doing a very, very good job. I think they are as busy as possible again. You know, we are trying to establish a system in the Netherlands where we have this integrated health system where I collaborate with my primary care colleagues and with the cardiologists and endocrinologists and with the cardiovascular and orthopedic surgeons to keep people healthy. That is our position, that is why we should be here, that is why I am here. Now they don't pay me to be here and talk. I think this is an important message for the community, that people understand things like this.

It sounds complicated, it really isn't, but ultimately it can be a huge help in keeping us healthy. I mean, I'm getting older too, so I want to stay healthy. I want I want my family to be healthy. no, I think about it again, I think a big part of this is that primary care doctors do what they prioritize things and do the things that are important to them, they can't, they can't do everything, there's also a lot of misinformation about Testosterone there are a lot of primary care doctors who think it's a bunch of nonsense and I don't believe that at all and that's still being worked out to be honest you know I'm a big proponent of this.

I think it can be maintained. we healthy and it's a very important thing to look at, you know, as my wife would say, doctors are sometimes right but they're never unsure and that's just how we are, we think we know everything and we don't know everything, and sometimes a little humility goes. a long way, so it's a good question here, so why do only 5% of men with hypogonads receive testosterone replacement therapy? This is a timely slide, so we like to blame the patients. I hate going to the doctor, but the patients are part of it. of the problem the doctors are part of the problem the symptoms are a normal part of aging, that's the doctors, I think that's what they told you correctly, evaluated incorrectly or not evaluated at all again, they take our testosterone level in the Holland Hospital and the proud man comes and says that the normal range is 180 to 700 and his testosterone returns to 200 that is normal no, it is not less than 300 it is abnormal so there has to be some consistency there are perceived risks of replacement therapy of testosterone prostate problems and these cardiovascular things that Again, if I can give you a stack of articles that are so interesting and so high that would support these are peer-reviewed academic articles that would support testosterone replacement therapy by looking at things like cardiovascular disease.

There are two articles that say the opposite is from the VA. and that should tell you enough: the VA document was a monstrous joke. There were women involved in this testosterone replacement therapy who never got testosterone. There were patients who had never filled their prescriptions. It was really a bad study. The other one that I referenced previously in the journal of the American Medical Association so let's talk about the treatment what are the goals the goals are all of these things improve libido mood feeling of well being muscle mass bone cardioproductive contraindications we talked about cancer breast and prostate you know large prostates sleep apnea congestive heart failure this is probably the only thing that from my point of view is a contraindication to administering testosterone replacement and it is a high blood count that the hemoglobin level is too high.

I think there are good studies showing that sleep apnea improves with testosterone replacement therapy. I rarely see prostate problems urinary problems in men who are on testosterone replacement therapy. You know, obviously breast cancer doesn't happen in men or it happens rarely. In my opinion, prostate cancer is not a contraindication to replacing testosterone, without a doubt, let's just focus on the sexual. function is a difficult topic for some people to talk about, but it's something that I think is really important again. I would tell you that there are many good studies that show that men with erectile dysfunction are at increased risk of heart attack and stroke.

I wrote an article. Having said that, erectile dysfunction can and can save your life, and I have had patients come to me for erectile dysfunction who we diagnose with heart and major heart disease. What are the

facts

? We know that lower testosterone levels decrease interest. in saks libido decreased spontaneous erections those morning erections and nighttime erections that we have are very important to keep things healthy are really important the loss of those erections can lead to major problems we know that testosterone replacement therapy has central and peripheral effects on our body as well as When it comes to sexual function, we know that in testosterone replacement therapy there is a higher frequency of sexual thoughts and desires and that is a normal part of things.

All of this is, in a sense, positive and good when it comes to testosterone replacement. Sexual therapy and function is a myth, although testosterone replacement therapy is a primary way to treat erectile dysfunction, it is not a supplement in some sense, but it is not a primary therapy, things like viagra, levitra and Cialis and injection therapy and penile implants or primary therapies, testosterone is Not so, let's look at testosterone replacement options. These are the options. You have come to me. We've talked about your testosterone. You have symptoms of low testosterone. We measure your levels. They're short.

We figured you had something like that. combination of a pituitary problem and a testicular problem and we're going to talk about trial testosterone replacement therapy right now a lot of testosterone replacement therapy is governed by the insurance companies the insurance companies will tell us what we can and we cannot do it, that is something of a reality because they are going to pay for things. I think transdermal gels, so this is a tube of gel that you can rub on your shoulder or chest, inner thigh, or under your arm daily. I think it is the most physiologically normal way to replace testosterone, you have to do it every day, you can infect your partner, which you don't want, insurance companies do not pay for this and are on the market, pharmaceuticals know this and they have been stolen. the price goes up and it's exorbitant so what happens is everyone starts on injection therapy so they give you an injection in your butt every two weeks and what I do is you get these injections every two weeks over the course of about ten weeks. and then we check your levels again, why a week after a mid-shot injection, it's very important to do it that way and in time for your sixth injection, you come back and we talk about your symptom response and I look at your lab responses . on your testosterone, your PSA blood tests and your hemoglobin and that's how we start in most patients, transdermal patches, these are these patches that we put on people who have fallen by the wayside and I can people These welts come out and they look like they've been attacked by an octopus, they itch and they're really a problem, so I'm going to fasten the discs back, this is a little, it almost looks like a little piece of cardboard that you put on the gum and the Testosterone is absorbed.

Most of those patients ended up with significant irritation of the gums and no one uses these oral preparations anymore, they cannot be found in other parts of the world, but what happens is that they transform, these medications that are taken orally and They swallow, they transform. but in your liver and they create liver tumors, that's a problem. Subcutaneous granules are a reasonable option. That's where I put a series of granules under the skin of your buttock. It takes about five minutes to do and can last six to nine months there. it is a newer injection in the United States now the standard injection lasts two weeks there is a newer injection that lasts ten weeks it has been around in Europe and Canada for 25 years all my Canadian and European colleagues when I go to meetings and talk to them they all use the ten week shot, it's not that it's not well thought out here, it's that when the FDA approved it, they approved it at a lower dose.

I have had several patients who have been taking the medication and do not respond. Alright, unfortunately it's not a great option, so I checked all of them. This is the biweekly injection that we use, probably about 75% of the patients in my practice are treated with this. I can teach you how to inject yourself. themselves at home, we still have to monitor them carefully and they have to have regular blood tests. Many patients come in and don't want to do it on their own, they come in and have it done in the office this is not approved in the United States it can be used in Europe and Canada this is the longer acting substance which again is a good option unfortunately he said it is at a suboptimal dose again these are the patches that we do not use I no longer use the gels, I think they are the best option, but they are very expensive, very, very expensive, the buccal discs, I talked about the LR test tube, the subcutaneous granules, so we wrap things up here.

I know we have gone a little further we know that testosterone is the main male androgen, the antigen is what makes us stronger, we know that low testosterone hypogonadism is a very common problem, five million people are affected, it is probably the triple, to be honest, I think or even more. The short and long term effects of low testosterone levels can be significant. The evaluation is very simple. The treatments are varied and, again, very simple. There are many different options for treatments and at this point I would tell you that there are certainly six treatments and they have very acceptable risks. and the advantage of treating patients significantly is greater than the negative risk and there is probably a greater negative risk of not treating not being treated.

I am more than happy to answer questions. I'm going to be here for a while. I appreciate everyone's support. Attention and I appreciate the questions and I hope this has helped you with some issues with low testosterone. Yes, this is just a replacement therapy and again, I think there is a lot of research being done on better options for long-term replacement therapy. so you don't have to come every week, you know, one of the problems with the shot every two weeks is that you get a big burst of testosterone and it drips for two weeks, it doesn't really do that, it's a little bit different, but that's not It is a physiological way that testosterone is released in our body.

Remember we have a small burst in the morning and it trickles down throughout the day. Therefore, gels are a better way to apply what you have to put on. every day and you can, there is transfer if you don't rub it and put it on before you go to bed and you know, hugging your wife, you could, you could, she could wake up with some kind of mustache, yeah, yeah. The skins are a little different. I liked the granules. I don't think there will be as vigorous a response to the pellets as there is with the injection every two weeks.

I think people get a good more vigorous feeling with the injections, but it's nice. What happens with the pellets is if you reach a steady state with the pellets and we know let's say you were on the pellets every nine months. I have a lot of patients like that, I see them every nine months and I do a blood test, essentially a couple of months before they arrive and I know where they are and it's pretty easy, so it's easy to follow. Yeah, it's not going down for a while. Pharmacists know I'm doing this. They like this. because I'm talking about these things that they do.

I have no association with any of the pharmaceutical products. No, I don't speak for them, no, no, I don't like to see them. In my office, to be honest, I think that on one hand they are salespeople, but they provide an important service. It's just that they are very interested in making profits and when they see things like this, they go crazy. prices are going up and expensive, they are not going to come down anytime soon, the other thing is that there are compounding pharmacies that are starting to release a cheaper version of the topicals that they make themselves, there are some problems with compounding pharmacies and safety of someinfections that occurred in the past so some of the compounding pharmacies are gone but some of the compounding formulations may be good we could see an increase in those on the market yes yes absolutely Perico is one of them and Perrigo it does.

I think that was a good job with some of the generic stuff, so yeah, again, I can give you a pile of articles so high that they would say quite the opposite, there are two articles that would suggest that you are at a higher risk of having a stroke. heart attack and stroke with testosterone replacement and both. A lot of those documents are remarkably poorly put together, so I'm all for that, yes, Blue Cross Blue Shield made some changes, but what the insurance companies do is they make some changes and they make it a little bit more difficult and a lot more. the doctors and the patients give up and the farm, their payer says no, we say okay, but if they say no and we say wait a minute, we send letters and bother them, they'll say yes, that's a good question , Yes I think so.

The problem is there are no studies to confirm that and with all natural supplements there have been no studies done so you don't really know and I wouldn't say no you shouldn't do that. For you, the only downside to doing it is your well-being, the cost out of pocket, and you're guessing, so yeah, it's a great question. I have a lot of patients who get medications at Canadian pharmacies and most of the patients I see who do that are patients who are looking for things like viagra and levitra cialis. I have rarely had patients have problems with those pharmacies and those pharmaceuticals again, there are no studies to show that they are effective or there are any. proof of its effectiveness, but I think there are some natural benefits that we can get from those remedies, it's just that there are no studies that confirm or support them well.

III would tell you that you know one of the things we need. We need a well-balanced diet, you know, cholesterol is the building block of testosterone, so you need cholesterol. Cholesterol is an important substance in our body. You know, fresh foods are really important. I think processed foods are a really bad thing. I think foods with high fructose corn syrup and those simple sugars are bad, those are the things that simulate our pancreas and create pancreatic problems and problems related to diabetes and fats, I think that's more important and Will it ultimately have any impact on testosterone production, no, no.

Don't lower your testosterone, no, because there is and, and I think this is a good question, you need a certain amount of cholesterol to build and produce testosterone, but you will have it regardless of how low you say your cholesterol is, so no, no. you did it. Is calcium bad for you? No, what, what, well, I think what you're referring to is that testosterone can act in a sense as a calcium channel blocker, which is why calcium channel blockers are given to people with high blood pressure. higher blood pressure and certain heart types. problems, it increases blood flow because it can allow more blood to reach certain organs and testosterone has a similar effect on blood vessels as calcium channel blockers.

Yes, Medicare is the same. Medicare is restrictive and Medicare and Medicare Supplement are restrictive. most Medicare patients will not be able to qualify for topical agents, if you mean treatment, yes, treatment, most of my Medicare patients are being treated with injections every two weeks, so yeah, you know. However, insurance can be fickle and they can have little things that they exclude, so you have to be very careful when you talk, when you have your insurance policy, you know if you have to know what is covered and what is not, but I struggle with companies insurance all the time regarding a lot of different things and I have all these form letters that we just write and sign and bother them and call Priority Health all the time.

I know the medical directors there, I'm sure they work. their eyes when they see me talking on the phone and it's not that it's not unpleasant, it's just that you know it's like the squeaky wheel if you are firm and dispassionate, you can do things, it's just a time-consuming subject. I think in many cases it depends on him. I think there are some primary care guys who like to stay in control and get things done and I'm very supportive of that too. I support those who say I'm going to take care of your diabetes and your high blood pressure and your heart disease and your cholesterol and I'm going to let the blood load take care of the testosterone, not once a month is wrong, yes.

I see that a lot once a month testosterone sip unit injection is not appropriate if you get a blood test at two weeks and you will be completely low so it's now and I'll take a step back. Secondly, I would tell you that as soon as I say that will always happen or never happen, I am wrong, there are some patients who probably do well with a monthly injection. I have a couple of people on a monthly injection, but the vast majority. of patients needed every two weeks and I can show you the data. I can show you the data for my patients to prove, so you can't call the office and we know that's a good thing about healthcare today.

I don't need references, you shouldn't if you want to come see us, we are more than happy to see you, it doesn't take long, you know our goal, there are four of us in this group. I do most of the testosterone. Things are coming to me, but you know our goal is not for people to wait six weeks to see us. Our goal is to see patients promptly and we're pretty good at doing that, and if things happen, you need to be seen. squeaky wheel just come in and we won't help you no one is waiting a long time well, if I saw you today and we talked about low testosterone levels, I thought you had symptoms of that, tomorrow morning I would take a blood test, in theory, that comes.

Within 24 hours the guidelines are pretty strict in saying if your testosterone comes back below 300 we have to confirm it with a second and the insurance companies are strict when it comes to that so what do I do if let's say your testosterone comes back ? At 220 you would be given a second testosterone and luteinizing hormone a few days later. It tells me what type of low testosterone you have and theoretically the next day we could treat you. You can do it. You can do it in less than a week. it's pretty quick yeah that's a good question so what happens when you get exogenous testosterone i.e. you get an injection in the butt or you get the gel or the pellets?

What that does is send a signal to the pituitary gland to decrease luteinization. The hormone or luteinizing hormone is what goes to the testicles and says to produce testosterone so that it is suppressed. There is a small percentage of patients where that suppression will be long-lasting, so once exogenous testosterone is stopped there is a chance that it will return to normal. of testosterone or your testosterone level will not return, that happens relatively rarely, but it can happen, there is also an option, for example, if I have a 25 year old who has low testosterone for whatever reason, I will not treat him.

With exogenous testosterone I will treat them with a substance that stimulates their pituitary gland called clomid and that is always an option. I included it here, but it's always an option that maintains sperm function and production and keeps it all it does is stimulate the testicles, but it really has to be someone who has a primary hypokinetic diagnostic test, so that's something what I always talk about with patients, it's an important complement to things, no, that's physiological, yeah, your libido, right? You know, men have a strong libido, we know that. We are men we are eager to do it and that is a reflection of your testosterone and libido is one of the most sensitive indicators of low testosterone when I have men come in and I ask them specifically if you are interested in intimacy and they say well , that's a red flag, so sometimes you have to dig a little deeper into that to figure it out because there can be other psychosocial issues in relationships and when I see patients with sexual dysfunction, whatever it is.

My preference is to see couples because I think that's all a couple problem and it's much more effective for me, from the point of view of evaluating patients correctly, treating patients correctly, seeing both partners, it works much better than that way. Being a sensitive emotional topic, not many people like to talk about it. I see many patients with sexual dysfunction. You know, what I would tell you is that we want to live our lives with people. They want to maintain their privacy. They want They want They do the things they want to do and they don't want to say well, I'm 65, I'm done, that mentality is falling by the wayside, anything else, well, thank you all for coming, I appreciate it and if you have questions. you can always call the office.

I'll talk to you on the phone if you have questions about anything. You don't need to be patient. If you have any questions about anything, please leave your name and number in the office. I call you back, it's good, you know, one of the best things about how I spent a lot of time in Grand Rapids in Grand Rapids is its spectrum. Holland does a very, very good job. It is a smaller hospital. I think it really appeals to the community and our goals of keeping the community healthy, so thank you all for coming, we appreciate