Is testosterone therapy right for you? Testosterone plays a crucial role in muscle growth, energy, and overall health, but it also ...

testosterone-is-amazing-or-is-it

Testosterone is Amazing (or is it?)

have you ever wanted to try testosterone but you've wondered is it really worth it and what are the risks I'm Dr Reena Malik urologist and pelvic surgeon and today I'm going to be talking all about testosterone replacement therapy the benefits the risks and who should really use it so trt is used for men who have what we call hypogonadism and what that is is essentially having low testosterone on blood work meaning getting your blood checked and seeing that the testosterone level is low usually lower than 300 nanog per decator as well as having symptoms of hypogonadism and these symptoms can be things like low libido brain fog meaning having difficulty with memory fatigue feeling less Vigor than usual mood changes like depression and having difficulty gaining muscle mass or increased fat gain and also erectile dysfunction particularly having difficulty with mour erections now hypog ISM becomes more common after the age of 40 and specifically if you have other what we call comorbid conditions this could be things like diabetes high blood pressure high cholesterol other metabolic issues that can make it more likely that you will develop issues with low testosterone now trt can be very effective in treating men who have hypog glism specifically for improving those symptoms I discussed about associated with hypogonadism but the real question remains is it safe so there was a landmark study that was published in 2016 in a very prominent medical journal called the New England Journal of Medicine and this study looked at the potential benefits of raising those testosterone levels with medication in men who were above age 65 so 65 and older who had moderately low testosterone levels so in this study the researchers recruited a total of 790 men these men had to have an average serum testosterone level of less than 275 nanog per deiler now these participants were then randomly assigned to receive either testosterone gel or a placebo gel for one year and in the trial this is called the testosterone trials the treatment significantly improved many measures specifically sexual activity sexual desire and erectile function compared to those who were taking the placebo gel so in terms of physical function men were able to walk further distances in six minutes so they looked at their six minute walking distance and they found those that were able to increase their Distance by about 50 m or 164 ft was about 20% in the testosterone group versus 12% in the placebo group which was significant they also noticed that they had greater increase in physical function scores on surveys and they generally perceived that their walking ability was better they also saw some small but significant improvements in mood depression and energy levels compared to the group that got the placebo gel and overall they were more likely to say hey my energy is better now this is a big deal because it showed that not only are you seeing improvements in sexual function you're also seeing improvements in physical function the ability to walk and the ability to move around in the world as well as Improvement in mood which can be really transformative for people who are feeling depressed now other Studies have also looked at a number of benefits one is body composition in terms of body composition other studies have found that men on trt for over 3 years gain an average of 1.9 kg or 4 lbs of lean body mass and lose about 6.5 lbs of fat Mass compared to those who don't receive trt they get really minimal increases and minimal decreases other Studies have also looked at things like stair climbing power and strength as well as power during chest press or leg press and seen improvements there's also improvements in bone density particularly in older men on trt they've seen improvements in volumetric bone density and Bone strength particularly in bones of the spine now you can understand why this is really important because as you age you not only want to increase your muscle mass but you also want to maintain your bone health so that if you fall you're not likely to fracture those bones now the majority of these studies are done again on men who are truly hypogonadal based on lab values and they have symptoms and they are typically older so usually above the age of 65 so what this means is that if you have normal levels of testosterone and you take extra that you may not see all the same benefits because we don't know if your testosterone receptors are truly saturated meaning are they getting enough testosterone to activate all those receptors and the more you get you're not going to see the same benefits now let's balance this there are some potential risks but there's also a ton of misinformation about the risks of trt so let's start with debunking some of that so some of the risks that people think are a big problem but are really not borne out in the data one of which is cardiovascular disease so many people have heard that trt can cause heart disease but is this actually true so it comes from some initial research on trt that showed sort of mixed outcomes in terms of improving versus worsening cardiovascular risks now in 2013 there was was a study that looked at 8,500 veterans who had undergone coronary angiography meaning they had an evaluation of their heart because they had heart disease and these men also had low testosterone and then got trt and what they found was that these men had a higher risk of Mi stroke and death in the group that got trt however there was some serious criticisms about this study because of flaws in design and data analysis specifically looking at how long they followed these men who got test testosterone and how long they had to be on testosterone before having a cardiovascular event like is it really due to the testosterone they also use some very complex statistical models that basically took the number of actual events which was actually lower in the testosterone treated group and made them more as higher adjusted rates so this was sort of controversial but it took off in the media it led to a ton of people stopping prescriptions of trt now after this another study looked at 83,000 men in the veteran system again with documented low testosterone now what they found was that trt was actually associated with a 33% lower risk of cardiovascular events and death over a followup of 4.3 years and the other important thing about this study was they actually looked at the men's trt after they got testosterone and specifically these benefits were seen in those men who got to normal levels and these men were 56% less likely to die during the follow-up period 24% less likely to suffer a heart attack and 36% less likely to have a stroke that is really really impressive I mean think about it if I told you that doing something could decrease your risk of death over the next four years by 56% that's pretty impressive now lastly there's new data from the Traverse trial now this is a randomized controlled trial that took over 5,000 men who were 45 years of age or older and they either had existing heart disease or they had a lot of risk factors like high blood pressure diabetes and obesity half of these men got daily testosterone gel and the other half received again a placebo gel so they did not have testosterone in it and after about 33 months almost 3 years they found that there was no significant difference in those groups in terms of the major cardiovascular events that they had as well as heart attack stroke or death from any cardiovascular event again saying hey testosterone replacement therapy is not increasing the risk of cardiovascular events there was also no difference in cardiovascular procedures or the incidence of heart failure between the groups to me based on all this data and again there is a lot of data here I only covered a small amount I would say that testosterone when used for men who have hypogonadism is safe and effective and should not cause an increased risk of cardiovascular events that does not mean that you should take it without followup because I'm going to talk about some of the other risks and you need close followup of your testosterone to make sure you don't put yourself at higher risk of other issues another myth is that testosterone worsens urinary symptoms for men now a recent observational study looking at 259 men with low testosterone and erectile dysfunction followed men who either got trt for 3 years or those who didn't and what they found was that their urinary symptoms based on symptom questionnaires was actually improved in the men on trt But Not only was their symptoms improved their bladder wall thickness improved and they had a reduced postvoid residual meaning they emptied their bladders better now it's important to note the study did not include men who had really bad or severe urinary symptoms generally this study showed the exact opposite of what people think about trt now a larger meta analysis which looked at 14 randomized control trials with over 4,000 men was completed to really investigate this and they found that b basically testosterone didn't change lower urinary tract symptom scores compared to Placebo now it didn't say it was better but it definitely didn't say it was worse the reason people think that urinary symptoms can occur with testosterone is because the prostate is very testosterone sensitive it may cause some prostate growth now regardless of this the prostate only has so many Androgen receptors and in fact those Androgen receptors are saturated at very low values of testost tone this will again come into play when I talk about prostate cancer so if they're already saturated adding more testosterone is not going to change the prostate to any significant degree and so ultimately that makes sense as to why you would not see worsening symptoms now as men age having an enlarged prostate or growing prostate can be very common and so you can still see symptoms but it may be attributed to other factors and if you want to learn about BPH a little bit more check out my podcast or my YouTube videos about that that content so you can learn more about it now I mentioned prostate cancer earlier so people think that testosterone replacement can cause prostate cancer now trt can cause a very slight increase in your PSA again because once those receptors are saturated it is going to increase prostate size and potentially PSA however in the totality of the current evidence there is no suggested increase in the incidence of prostate cancer of men on trt and this is again likely because those receptors are already saturated it is important however if you develop prostate cancer which is very common seen in one in eight men you don't want to remain on testosterone so it again is very important to continue to monitor your PSA while you're on testosterone there was a study looking at 150,000 men over 15 years looking at those who developed prostate cancer who were on trt and they found no statistic Ally significant difference in terms of overall survival or prostate cancer specific survival between the men who use trt versus those who hadn't they even found that the men who developed prostate cancer had more favorable results in terms of their cancer outcomes compared to those were not on trt specifically looking at tumor grade and clinical staging all right let's move on to some real risks one we know that trt can lead to water retention and swelling so if you have heart failure or issues with fluid retention this may exacerbate those issues another one is sleep apnea so in a study they saw 10% of men who were on trt developed or had worsening sleep apnea compared to 4% in the placebo group this is something you need to keep in mind if you are prone to snoring or you have a very large neck circumference those are usually signs that you may suffer from sleep apnea if this is the case you may want to get a sleep study to evaluate for sleep apnea make sure you optimize that before you start testosterone replacement also some data suggests that this might actually just be temporary that if you have this exacerbation after about 18 weeks you might notice some improvement in your symptoms also it may be more common in men who are taking very high doses of trt next up blood clots now blood clots come up a lot with any sort of hormone replacement whether it's for women with estrogen or men with testosterone but let me share some data on this so there was a case control study that was published in yet another prominent medical journal called jamama internal medicine or the Journal of American Medical Association that found that men who Ed testosterone in the past 6 months had a 63% higher risk of developing blood clots compared to non-users now this risk is typically highest in that first 6 months of treatment and then went down however after this study there was a systematic review so a much bigger review combining 13 randomized control Trials of 5,000 men looking at men who got testosterone versus those who got a placebo and following them from anywhere for 3 months to 3 years and they found no significant association between testosterone replacement blood clot deep Venus thrombosis so clots in your legs or in your lung So based on this study which is the largest most comprehensive study they see no Associated increased risk now they did describe the study as having some lowquality evidence and there may be clinically important risk so regardless if you are at high risk of blood clots is an important discussion to have with your doctor next up is fertility so when you take trt the increase in your testosterone that you get in your blood sends a negative feedback signal to your brain in your pituitary gland telling it don't send any more signals to make testosterone because we have enough and this can then also cause a reduction in sperm production in a study in the Journal of Urology they found that after 6 months of trt about 65% of men had sperm concentration drop to Less Than 3 million per milliliter which is considered severe oligospermia or severe low sperm count so if you're planning on starting a family make sure you check out my video where I talk about the options for testosterone or off Lael options that you can use depending on what the timing is for when you want to have a family next one is erythrocytosis or called blood thickening now the reason people worry about this is because this when your blood is thicker or more viscous it can put you at higher risk for events like blood clot or stroke so a systematic review and a metaanalysis was published in the journal of clinical endocrinology and Metabolism it found that trt increased hematocrit or the number of red blood cells by an average of 3.1% now this increase could potentially increase the risk again of blood clots especially in men who already have high hematocrite levels so typically your doctor will check those before you start however there was no serious Adverse Events meaning there was no stroke no blood clots reported during the duration of the study now the risk of this Blood thickening tends to increase with age with higher Doses and certain formulations specifically injectable trt which has a higher rate of this compared to maybe gels or oral medications now it's important regardless of whatever formulation you get prescribed or whatever dose you're on you need to have continued follow up are you catching my drift here it is really important to follow up when you're on testosterone replacement therapy even if you feel great even if everything feels wonderful you need to get your your blood levels checked on a regular basis now what else acne and oily skin some men do experience acne or oily skin while you're taking trt now this is not life-threatening but it can be bothersome now some men can also experience breast enlargement or what we call gynecomastia now this can happen because trt or testosterone specifically gets convert in the blood to estrad and estral can cause some of this breast enlargement and this may require either changing of doses or addition of other medications next up hair loss so I've discussed hair loss and testosterone in a prior video um so check that one out but basically the bottom line is yes you can develop hair loss particularly if you are genetically pre-disposed to losing your hair or male pattern baldness in your family so testosterone replacement in those cases May expedite hair loss so who ultimately benefits from trt well Society guidelines will recommend trt for men who have a consistently low morning testosterone usually below 300 nanog per Deiter twice on blood testing as well as symptoms of low testosterone including decreased libido erectile dysfunction brain fog change in mood decreased muscle mass increased fat gain all those things as well as erectile dysfunction can be a sign of low testosterone now what about contraindications so contraindications would be active prostate cancer severely uncontrolled sleep apnea and it's generally not recommended for men who want to father children in the future or if you have breast cancer or uncontrolled heart failure remember it can cause swelling so ultimately trt can be very beneficial for men who have low testosterone levels and symptoms but it is not risk-free it's crucial that you have a thorough discussion with your doctor about your individual risks and benefits because you have a unique medical history that is really important to take into consideration it is a serious medical treatment and requires again careful monitoring and followup so if you're considering trt make sure to work with someone who's knowledgeable and who can guide you through the process safely I just want to take this moment to remind you guys if you're new here or you haven't been here for a while I have started a podcast called the reen Malik MD podcast you can find it here on YouTube but you can also find it on any podcast platform so you can listen to it on your commutes on your walks and I interview expert guests I give long form podcast content as well as ask me anything so check it out let me know what you think let me know what you want to hear or who you want to hear from and as always remember take care of yourself because you're worth it

Dr.

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