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MEN’S HEALTH MEN’S HEALTH

place patients at an increased risk for cardiovascular complications like These patients may be offered the medication Clomid, which is a non-
stroke and heart attack. PSAs should be measured as well, as the initia- steroidal stimulant. This acts on the pituitary gland to stimulate more
tion of TRT can cause an elevation of the PSA. Elevated PSAs prior to natural production of FSH and LH and causes intrinsic production of
induction of TRT raise concern for the possibility of an occult pros- testosterone while preserving fertility. A standard dose is 50mg daily
Testosterone Therapy: tate cancer and need stronger evaluation before proceeding with TRT. PO, but can be increased to 75mg PO daily, based on the patient's
weight and lab results.
Applications of Testosterone Therapy
Injectable Testosterone: The most common form of TRT still
Solution or Problem? remains injectables. Testosterone Cypionate and Enanthanate are very References:
1. Baillargeon, J, Urban, RJ, Ottenbacher, KJ, Pierson, K & Good-
commonly prescribed by practitioners. They are affordable and easy
By Matthias D. Hofer, MD, PhD, and to titrate. The AUA recommends starting patients at 100mg of either win, JS. (2013). Trends in androgen prescribing in the United
D. Scott Christensen, RN, MSN, ACNP-BC agent, once a week. It is sometimes given as 200mg every other week, States, 2001 to 2011. JAMA Internal Medicine, 173(15), 1465.
but this should be discouraged, as the risk of polycythemia increases https://doi.org/10.1001/jamainternmed.2013.6895
Testosterone Replacement Therapy (TRT) continues to grow in pop- Proper Diagnosis of Testosterone Deficiency and persists longer when given in larger doses. If administered in this 2. Baillargeon, J, Urban, RJ, Kuo, YF, Holmes, HM, Raji, M, Mor-
ularity thanks to radio, internet and social media advertisements and testi- Clinicians should make a proper diagnosis of testosterone deficien- manner, the patient tends to feel great for the first week, then “crashes” gentaler, A, Howrey, B, Lin, YL & Ottenbacher, KJ. (2015).
monials. Its initial popularity in the realm of men’s fitness has expanded to cy (TD) with both a low testosterone level and the presence of select the next. It can create a rollercoaster effect on the patient. Screening and monitoring in men prescribed testosterone therapy
include promises that often are misstated and negative impacts when use symptoms, such as reduced energy, poor libido, reduced endurance, Newer studies are showing that T Cypionate and T Enanthanate in the U.S., 2001–2010. Public Health Reports, 130(2), 143–
escalates without appropriate monitoring and management. fatigue, depression, poor concentration or changes in erectile function. can be given subcutaneously instead of intramuscular. This tends to be 152. https://doi.org/10.1177/003335491513000207
Often physical results drive its use absent informed management. The American Urological Association (AUA) defines the presence of gentler on the body and does not typically cause polycythemia because 3. Mulhall, JP, Trost, L, Brannigan, RE, Kurtz, EG, Redmon, JB,
Testosterone’s currently accepted medical use in the United States is TD as a testosterone level consistently lower than the threshold of of the absorption route. T Cypionate is easier to inject SQ vs Enanthate Chiles, KA, Lightner, DJ, Miner, M, Murad, MH, Nelson, CJ,
focused on testosterone deficiency (hypogonadism), but it must be 300ng/dL on at least two consistent serum levels, obtained early in due to its carrier oil. Testosterone Cypionate uses olive oil as its carri- Platz, EA, Ramanathan, L & Lewis, RW. (2018). Evaluation and
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strictly monitored. Testosterone can be administered via injections, the morning. Men’s T levels are naturally highest in the morning, so er. Olive oil is far more fluid than sesame oil, almost like water, so it is a Management of Testosterone Deficiency: AUA Guideline. The
topical gels, oral pills and even subdermal pellets. All therapies can be most insurance care plans will not cover therapy unless two morning preferable choice in administering TRT via the subcutaneous route as it Journal of Urology, 200(2), 423–432. https://doi.org/10.1016/j.
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very effective in bringing patients back to a eugonadal state. Manage- T levels are obtained. is less likely to congeal and is a more effective delivery system. juro.2018.03.115
ment remains essential. Other patients who could consider screening for TD include Topical Therapies: Topical ointments can also be used. These 4. Citron, JT, Ettinger, B, Rubinoff, H, Ettinger, VM, Minkoff, JR,
patients with a history of unexplained anemia, bone density loss, have been around for quite some time, are easy to apply and tend to Hom, F, Kan, PB & Alloo, R. (1996). Prevalence of Hypotha-
Background of Testosterone Replacement Therapy diabetes, exposure to chemotherapy, exposure to testicular radiation, work best in the older population. As therapies evolve, the choice of lamic-Pituitary Imaging Abnormalities in Impotent Men with
Testosterone is an essential hormone for males produced primar- HIV/AIDS, chronic narcotic use, male infertility, pituitary dysfunc- medication treatments often is dictated by the insurance carrier. Most Secondary Hypogonadism. The Journal of Urology, 155(2),
ily in the testicles and is required for differentiation, developmental tion or chronic corticosteroid use. These are targeted patients, and do topical testosterone solutions come in a generic formulation, so autho- 529–533. https://doi.org/10.1016/s0022-5347(01)66441-3
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growth, and maintenance of phenotype; namely. not necessarily need to have symptoms and signs of TD. rization tends to be easier to obtain. However, these should be avoided 5. Choi, E, Xu, P, Barham, DW, El‐Khatib, FM, Yafi, FA &
• Bone density in men who come into close contact with grandchildren or children in Kavoussi, P. (2022). Comparison of Outcomes for Hypogo-
• Fat distribution Adjunctive Testing general, as the risk of contact transference is high. nadal Men Treated with Intramuscular Testosterone Cypionate
• Muscle strength and mass Unfortunately, it is all too common for some younger men who Oral Options: There are currently three different types of oral versus Subcutaneous Testosterone Enanthate. The Journal
• Facial and body hair have been diagnosed with TD, to be placed on improper therapies. testosterone formulations. They are listed as Tlando, Jatenzo and Kyza- of Urology, 207(3), 677–683. https://doi.org/10.1097/
• Red blood cell production Any younger male wishing to maintain his fertility should absolutely trex. These are all newer medications, so a generic is not available. They ju.0000000000002301
• Sex drive not be placed on any form of exogenous TRT, without consulting with are a good option for the patient who has needle phobia or just prefers 6. Park, HJ, Ahn, ST & Moon, DG. (2019). Evolution of guidelines
• Sperm production a urologist. Patients with TD desiring fertility should initially have an oral route. Previous oral formulations were found to cause hepato- for testosterone replacement therapy. Journal of Clinical Medi-
their serum FSH (follicle stimulating hormone), LH (luteinizing hor- toxicity and were removed from the market. These new formulations cine, 8(3), 410. https://doi.org/10.3390/jcm8030410
Testosterone levels generally peak during adolescence and early mone) and prolactin levels checked. FSH is responsible for intrinsic avoid the hepatic first pass system, and are absorbed directly within the
adulthood. As men age, the testosterone level gradually declines — production of sperm, while LH is responsible for the production of small intestine, so they should be taken with food. Matthias D. Hofer, MD, PhD, is a board-certified urologist at
typically about one percent per year after age 30 or 40. For older men, testosterone. By measuring these, it can help the practitioner differ- Subdermal Testosterone Pellets: Testosterone subdermal pel- Urology San Antonio’s Men’s Health and Wellness Clinic. He
it is important to determine if a low testosterone level is due to normal entiate between primary and secondary hypogonadism, and therefore lets are also a great option for the patient who does not like injections sees a variety of patients ranging from general urology concerns
aging or if it is due hypogonadism. 6 provide the proper treatment. and is looking for a long-term simple TRT option. Pellets are inserted to reconstruction and trauma. After completing his six-year
Hypogonadism hampers the ability to produce normal amounts of Prolactin levels should be considered in the screening of young under the skin in the buttock area and slowly release testosterone into residency in Urology at Northwestern University in Chicago, Dr. Hofer
testosterone due to a problem with the testicles (primary hypogonad- male patients as well. Persistently elevated prolactin levels could pos- the body over the course of four or five months. Once in place, they specialized further in one of the country’s top-ranked fellowships for Urologic
ism) or with the pituitary gland (secondary hypogonadism). Multiple sibly indicate the presence of pituitary tumors, such as prolactinomas, do not need to be removed and absorb over time. Testopel is the only Reconstruction, Trauma, and Prosthetics at UT Southwestern in Dallas.
treatment modalities exist for this condition and can greatly and effec- and the patient should be referred to an endocrinologist for further FDA-approved subdermal testosterone replacement therapy. These He also completed a three-year residency in Pathology at Harvard and
tively treat symptoms in these men. evaluation. For patients presenting with a Total T level <150ng/dL can be done in the urology office in about five minutes. Patients are earned a PhD. Dr. Hofer is a member of the Bexar County Medical Society.
Testosterone use in the United States has tripled from 2001 to 2019, and a low LH, a pituitary MRI should be done regardless of prolactin usually very satisfied with the results and convenience factor.
mostly in men without a clear medical indication for its use. Some levels to properly identify pituitary adenomas. 3,4 D. Scott Christensen, RN, MSN, ACNP-BC, treats men’s general
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studies have estimated that up to 25 percent of men receiving TRT have Lastly, a baseline PSA, hemoglobin and hematocrit should be Testosterone Therapy in the Patient Desiring Fertility urologic health concerns at Urology San Antonio’s Men’s Health
not even had their initial T level checked prior to initiating therapy, and obtained prior to starting any therapy. TRT commonly stimulates the It is not uncommon to see young men of childbearing age who have and Wellness Clinic at the Medical Center location. Scott earned
nearly half of those individuals do not have their levels checked after production of red blood cells (polycythemia). If the patient’s baseline been improperly treated with TRT, placing them at risk for issues with his Acute Care Nurse Practitioner degree from the University
initiating therapy. It is also estimated that up to a third of these men do Hct is >50 percent, then TRT should be held until the etiology is for- infertility. Exogenous testosterone shuts down the hypothalamic-pitu- of Texas Health Science Center San Antonio in 2013 and has worked
not meet the criteria to be diagnosed as testosterone deficient. 2,3 mally investigated. Secondary polycythemias caused by TRT can easily itary-gonadal (HPG) axis, and can shut down natural spermatogenesis. exclusively in Men’s Health for Urology San Antonio since that time.

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