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Category : Low T

New Guideline for Testosterone Treatment in Men With ‘Low T’ – Medscape

The American College of Physicians (ACP) has released new clinical guidelines providing practical recommendations for testosterone therapy in adult men with age-related low testosterone.

The evidence-based recommendations target all clinicians and werepublished online January 6 in Annals of Internal Medicine, highlighting data from a systematic review of evidence on the efficacy and safety of testosterone treatment in adult men with age-related low testosterone.

Serum testosterone levels drop as men age, starting in their mid-30s, and approximately 20% of American men older than 60 years have low testosterone.

However, no widely accepted testosterone threshold level exists that represents a measure below which symptoms of androgen deficiency and adverse health outcomes occur.

In addition, the role of testosterone therapy in managing this patient population is controversial.

"The purpose of this American College of Physicians (ACP) guideline is to present recommendations based on the best available evidence on the benefits, harms, and costs of testosterone treatment in adult men with age-related low testosterone," write Amir Qaseem, MD, PhD, MHA, from the American College of Physicians, Philadelphia, Pennsylvania, and colleagues.

"This guideline does not address screening or diagnosis of hypogonadism or monitoring of testosterone levels," the authors note.

In particular, the recommendations suggest that clinicians should initiate testosterone treatment in these patients only to help them improve their sexual function.

According to the authors, moderate-certainty evidence from seven trials involving testosterone treatment in adult men with age-related low testosterone showed a small improvement in global sexual function, whereas low-certainty evidence from seven trials showed a small improvement in erectile function.

By contrast, the guideline emphasizes that clinicians should avoid prescribing testosterone treatment for any other concern in this population. Available evidence demonstrates little to no improvement in physical function, depressive symptoms, energy and vitality, or cognition among these men after receiving testosterone treatment, the authors stress.

ACP recommends that clinicians should reassess men's symptoms within 12 months of testosterone treatment initiation, with regular re-evaluations during subsequent follow up. Clinicians should discontinue treatment in men if sexual function fails to improve.

The guideline also recommends using intramuscular formulations of testosterone treatment for this patient population instead of transdermal ones, because intramuscular formulations cost less and have similar clinical effectiveness and harms.

"The annual cost in 2016 per beneficiary for TRT [testosterone replacement therapy] was $2135.32 for the transdermal and $156.24 for the intramuscular formulation, according to paid pharmaceutical claims provided in the 2016 Medicare Part D Drug Claims data," the authors write.

In an accompanying editorial, E. Victor Adlin, MD, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, notes that these new ACP guidelines mostly mirror those recently proposed by both the Endocrine Society and the American Urological Association.

However, he predicts that many clinicians will question the ACP's recommendation to favor use of intramuscular over transdermal formulations of testosterone.

Although Adlin acknowledges the lower cost of intramuscular preparations as a major consideration, he explains that "the need for an intramuscular injection every 1 to 4 weeks is a potential barrier to adherence, and some patients require visits to a health care facility for the injections, which may add to the expense."

Fluctuating blood testosterone levels after each injection may also result in irregular symptom relief and difficulty achieving the desired blood level, he adds. "Individual preference may vary widely in the choice of testosterone therapy."

Overall, Adlin stresses that a patientclinician discussion should serve as the foundation for starting testosterone therapy in men with age-related low testosterone, with the patient playing a central role in treatment decision making.

This guideline was developed with financial support from the American College of Physicians' operating budget. Study author Carrie Horwitch reports serving as a fiduciary officer for the Washington State Medical Association. Jennifer S. Lin, a member of the ACP Clinical Guidelines Committee, reports being an employee of Kaiser Permanente. Robert McLean, another member of the committee, reports being an employee of Northeast Medical Group. The remaining authors and the editorialist have disclosed no relevant financial relationships.

Ann Intern Med. Published online January 6, 2020. Full text, Editorial

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Expert Insights on Osteoporosis From the ACR/ARP 2019 Annual Meeting – Rheumatology Advisor

The Great Debate at the 2019 ACR/ARP Annual Meeting addressed the issue of whether anabolic therapies are appropriate as first-line treatment for glucocorticoid-induced osteoporosis (GIO). The risk is usually defined based on previous fracture history, low T-score, and the presence of multiple risk factors for fracture including smoking, alcohol, or low body weight. Kenneth Saag, MD, presented the pro side while Mary Beth Humphrey, MD, PhD, presented the con side of using anabolic agents for GIO.

Audience members were surveyed on their opinion, with 60% of participants indicating their preference for using anabolic agents including teriparatide as first-line therapy for GIO. It was interesting to see this audience response, as certainly those advocating the use of teriparatide won. I was actually surprised the margin wasnt even greater for the pro side, because clearly anabolic drugs are superior to any antiresorptive agents for fracture protection in high-risk patients, with better bone efficacy data.

The main problem is that there have been no head-to-head trials conducted with fracture reduction as a primary end point for GIO. Several trials have shown bone mineral density (BMD) differences between drugs. Dr Saag noted in his presentation that research has found statistically significantly fewer fractures in patients taking teriparatide, but again, the fracture rate was not indicated as a primary end point in the design of the clinical trial. There also may never be a head-to-head trial for various drugs in GIO, the main reason being obviously the cost of conducting such trials.

Dr Humphrey indicated that patient preference, satisfaction, and adherence should also be taken into account when debating whether anabolic agents should be given to a patient at high risk for GIO, suggesting that some patients will not elect to receive medication delivered by injection. In general, patients dont want an injection when they can be prescribed a pill. From my point of view, the conversation should then shift to which is the best and most effective drug given your risk factors. From there we usually can come to a consensus that may include an anabolic agent. As for medication adherence, a patient who has a history of vertebral fracture and back pain may be more likely to be adherent than someone who is asymptomatic.

What I have found to be the larger issue, not only for payers but also patients, is the cost of the anabolic agents, especially for patients with Medicare who are dealing with the donut hole: those who are unable to use copay cards available to other patients with commercial insurance.

From a pathophysiologic perspective, I like to refer back to studies referenced in the past that point to the foundational effect of an anabolic. Researchers studied the effects of alendronate vs romosozumab in postmenopausal women with osteoporosis in the ARCH trial (Study to Determine the Efficacy and Safety of Romosozumab in the Treatment of Postmenopausal Women With Osteoporosis, Identifier: NCT01631214). This trial found that patients who were treated with romosozumab for 1 year followed by alendronate had a significantly lower risk of fracture compared with patients treated with alendronate alone. The fracture rate in people who had taken romosozumab in the first year was significantly less because of the foundational effect of the drug. The process consists of laying down new bone and then consolidating that new bone formation. That is what we have always had to consider, and this speaks to Dr Humphreys point that you do need to continue on an oral bisphosphonate after romosozumab to consolidate the bone after treatment with an anabolic. I like to tell my patients that this process of building bone is like a spring: first you expand the spring, then you have to prevent bounce back to the set point.

Dr Saag mentioned that he was not advocating anabolic agents as first-line treatment for every patient; these agents should be reserved for high-risk patients. I absolutely agree with him. We do not want to give teriparatide, abaloparatide, or romosozumab to everyone. In some patients, oral bisphosphonates are perfectly appropriate, such as those patients taking steroids.

Another point that was mentioned during the Great Debate was the risk for osteosarcoma, which was mainly derived from rat toxicology data using Fischer rats with open epiphyses their entire lives. The incidence of osteosarcoma was found to be markedly higher at baseline compared with humans. However, this osteosarcoma risk was noted by researchers; a registry was started to examine this link, and a drug length use limitation is imposed with some drugs. The registry is still insufficiently powered, so we are not yet certain that there is no relationship between the drugs and the risk for osteosarcoma. Thus far, various tumor registries in the United States have looked at the incidence of osteosarcoma with teriparatide use and no increased signal has been found.

Currently use of romosozumab is limited to 1 year because the effect tends to wane after 12 months. This is probably because the effect on osteoblasts is so potent that it depletes the osteoblast, and after a year there is nothing left to do. After 1 year, romosozumab becomes an expensive antiresorptive drug. What is further notable is the lack of information on the label about retreatment, as well as the lack of further guidelines about retreatment.

The current gaps in preventing glucocorticoid-induced osteoporosis are similar to those present in preventing postmenopausal osteoporosis. The number of people in whom bone density is being measured and who are being diagnosed with osteoporosis is decreasing. I think some patients may be risk averse because of the issues related to atypical femur fractures and osteonecrosis of the jaw. I think physicians may also be too busy to elevate this issue, even though mortality after hip fracture in women is 20% after one year and in men its 40%.

More broadly speaking apart from GIO, I believe the biggest game changer in osteoporosis research being presented is romosozumab. We now have a new anabolic agent that works differently than teriparatide as a signaling pathway drug. STUCTURE (An Open-label Study to Evaluate the Effect of Treatment With Romosozumab or Teriparatide in Postmenopausal Women; Identifier: NCT01796301) studied the effect of 1 year of treatment with romosozumab compared with teriparatide on total hip BMD in postmenopausal women with osteoporosis who were previously treated with bisphosphonate therapy. The investigators found a dramatic increase in BMD with romosozumab therapy compared with teriparatide. Importantly, they also conducted finite element analysis at the hip that showed increased hip strength with romosozumab. Given these data, I believe this is the biggest story right now in osteoporosis.

Disclosure: Dr Deal is a speaker and consultant for Radius and Amgen.

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Expert Insights on Osteoporosis From the ACR/ARP 2019 Annual Meeting - Rheumatology Advisor

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8 Awful Things That Happen to You After You Turn 30 (And What You Can Do to Stop Them) – Mandatory

A lot of things in life get better after you turn 30. Unfortunately, your testosterone level isnt one of them. Testosterone peaks during adolescence and young adulthood, but as men age, this manliest of hormones begins to drop by one percent each year beginning at age 30, and the decline affects your body and brain in myriad ways. Were going to unpack the eight unfortunate effects of low T, but just because biology has it in for you and your masculinity doesnt mean you have to take these changes lying down. (In fact, lying down may be one of the worst things you could do.) There are strategies to combat plummeting T levels, and were going to help you figure out which ones might work for you.

To be blunt, testosterone is what makes you want to fuck. As T decreases in your system, you may find the urge to mate is less intense. Suddenly, you can take sex or leave it. Youd rather binge watch a good show, eat a bucket of fried chicken, and fall asleep in your recliner than swipe through Tindr looking for your next one-night stand.

What you can do: Get moving! Exercise pumps blood throughout your body, cock and balls included. Indulge your fantasy life (yes, this means all the porn, but it could also include erotic reading and role-playing with your partner). Build anticipation by planning a date night and getting excited about the sex it will inevitably involve; make a playlist, set the scene, take a long shower and primp beforehand.

The most disturbing side effect of low T is the inability to get (or keep) it up. Suddenly, your once rock-hard, go-all-night member is acting like a lazy stoner. While the occasional dick disappointment is nothing to be concerned about, if your cock is failing to crow on a regular basis, its time to call in the professionals.

What you can do: They make drugs for this, and for good reason. Viagra is just one of the options for medically-induced erections you can discuss with your doctor. If boner pills dont work, testosterone replacement therapy may also be necessary.

Testosterone is what gives muscles that pumped-up look. As your T dips, your muscles deflate, and what was once high and tight is now soft and saggy.

What you can do: Make sure your exercise routine incorporates cardio and strength training. Either of those alone wont be enough. You need them both. Get more sleep so that when its time to hit the gym, youre raring to go. Recover with high-protein foods to give your muscles a boost. You can also talk to your doctor about whether testosterone supplementation is right for you.

Its so unfair. Youre not even a dad but youve been cursed with dad bod. Blame low T. Beyond the aesthetic of a fuller shape, though, the real danger in weight gain (no matter what the cause) is that it increases your risk of Type 2 diabetes, heart disease, and some cancers.

What you can do: Theres no shortcut here. You have to lose weight. And to do that, youll have to burn more calories than you consume. This means cutting out any empty calories and replacing them with healthy foods in addition to exercising. If youre already athletic, now is the time to step up your exertion and work out harder. Seek out a trainer if you need some ideas on how to make that happen.

Low T can mess with your sleep at night, leaving you drowsy and unmotivated by day. You might feel like youre dragging a giant sandbag previously known as your body around. Your usual get-up-and-go is more like crawl-into-a-hole-and-sleep-until-spring.

What you can do: Were going to sound like a broken record, but here goes: exercise! It seems counterintuitive, but by expending energy, youll gain more oomph. Low energy also means its time to tweak your diet and make sure that youre fueling your body with high-quality calories from whole, healthy foods, not processed ones purchased at the gas station or drive-thru window.

Feeling anywhere from mildly blue to downright depressed is common when testosterone levels start to dwindle. You may also feel irritable or experience mood swings.

What you can do: Youve heard it before, but it bears repeating: exercise and diet are crucial in mediating your mood. Yoga and meditation can help you find your Zen. Therapy can be a beneficial way to unload your feelings without taking them out on your loved ones. Antidepressants may also be warranted if your depression is severe and/or persistent.

If only this meant we forgot all our former fuckups, that ex we cant stop obsessing about, and how little our boss appreciates us! Unfortunately, low T means your brain is like Teflon: new information slides right off and doesnt get stored as reliably as it used to. You forget what room the morning meeting is in, what the new guys name is, or the cross streets of that restaurant you wanted to check out at lunch.

What you can do: A daily meditation practice can help the brain maximize its memory storage space. If meditation puts you to sleep, no worries; naps are good for your brain, too. Some studies show that caffeine, berries, and chewing gum may improve memory functioning. Play brain games like sudoku and crosswords to keep your grey matter in tip-top shape. Finally, be proactive: if you're likely to forget something, write it down or set an alert on your phone.

Low T levels means your hair on your head and your face falls out easier. It sucks, though the one upside is if you have a hairy back (or other unflattering hairy areas), they, too, might just resolve themselves. Hello, dolphin bod!

What you can do: Try Rogaine. Look into laser treatments. Spring for a surgical follicle hair transplant. Or say fuck it and shave your head. (Its badass and plenty of ladies love the look.)

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8 Awful Things That Happen to You After You Turn 30 (And What You Can Do to Stop Them) - Mandatory

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Homeless with HIV: A place to heal becomes a matter of life or death – OregonLive

This is the second part of a two-part series about the rise in HIV among homeless people. The first part examines how the public and private health systems must adapt after being caught unprepared to deal with the challenges of this outbreak.

James Macht sat in emergency rooms five or six times over the summer, wasting away. Lanky on his best day, the 6-feet-2 man continued to drop weight until he hit 115 pounds, suffering from poor nutrition and uncontrollable diarrhea caused by his HIV.

Then on Aug. 14, OHSU Hospital finally admitted him with a fungal infection on his arm, bronchitis and norovirus, which he suspects he picked up sleeping in Portlands crowded homeless shelters.

Machts T-cell count, an indicator of how strong the immune system is, was in the single digits. A healthy count is 400 or higher.

Macht is among the thousands of homeless people nationwide who make up a recent spike of HIV cases. The Portland area is one of the hardest hit by this new front of HIV transmissions, surging among intravenous drug users and their sexual partners. In Multnomah County, 71 people were diagnosed with HIV this year, nearly doubling the number reported in that population in 2016 and 2017 combined.

The outbreak is increasingly difficult to contain because of people like Macht, who languish while trying to find the stable housing they need to help them effectively treat their HIV.

In the Portland area, social workers and health care providers are rushing to adapt to the challenges of finding homeless people and helping them get on medication. Its a race against time to prevent the virus from spreading -- and to keep those infected alive.

But they find, for homeless patients like Macht, it can be impossible to take a daily pill when each day is a trial to survive.

Thats what haunted Macht during his three months at OHSU, as he slowly gained weight until he reached 150 pounds. He knew decades of untreated HIV had ravaged his immune system to the point that a lack of good food and proper hygiene, and exposure to the Pacific Northwests wet winter would likely lead back to the ER or worse.

But his options looked grim: he could enter a nursing home at the age of 41, hold out hope for a permanent home to come through, or be discharged back to the street.

I know I cant stay here forever, he said as he tried to balance his fifth cup of coffee for the day with shaky hands. I dont know what to do when I walk out of the hospital, man. Im not going to make it through another winter out there.

HIV led to the street

Macht contracted HIV from an ex-girlfriend who used intravenous drugs.

At the time, he didnt know she had HIV hes not even sure she did. By the time hed tracked her down after his diagnosis, she was already dead.

Macht, who says he has never done intravenous drugs, was confused when he started to feel tired all the time. Hed sleep 10 hours straight only to wake up exhausted again. He constantly came down with respiratory and other infections. Thinking it was something minor, he kept his job as a traveling salesman and was in Texas by the time of his fourth hospital visit for mysterious symptoms, which he later learned was a rare type of pneumonia.

His virus had torn into his body for so long that the white blood cells the virus targets T-cells -- had dropped hundreds of points below a healthy average. Macht asked his doctor what this pneumonia meant for him, but he said the doctor clapped him on the shoulder and said, Dont worry about it. You have AIDS. Then walked out.

At first, he just lay in bed for hours paralyzed with despair. He was told he had seven years left. At most. Still, he resumed his job, hoping he could at least keep busy. He was knocking on doors in Portland selling cleaning solutions when he again became too sick to work.

Macht checked into the hospital and by the time he was released a month later, hed lost his job because he couldnt keep up with the schedule. He returned to a motel until his money ran out and then ended up on Portlands streets.

There, Macht became one of a growing number of homeless people on the West Coast who then find that HIV becomes yet another barrier to access stable housing and in turn, whose lack of stable housing tends to make them sicker.

Portland, like most places, doesnt provide a special path to homeless services for people with HIV. Federal studies have found that the number of homeless people with HIV rose from more than 7% to 9% between 2015 and 2017, the first three years of a five-year plan for health agencies across the country sought to reduce it to 5%. The percentage continues to grow. Thats alarming because data also shows that people who dont have homes are less likely to see a doctor regularly and even less likely to achieve good health if they are in treatment.

But no matter how sick and immobile Macht and people in his position become, they have to produce the same paperwork, show up to the same offices and stand in the same lines as everyone else who needs a place to live.

James Macht meets with Mary Tegger, a physician's assistant at the Multnomah County HIV Clinic in downtown Portland. November 12, 2019 Beth Nakamura/Staff

Hard to stay healthy

AIDS used to be a death sentence. But as the decades have passed, medication has become so effective that the line between HIV and AIDS is largely a measure of temporary severity. Someone with a T-cell count below 200 is considered to have AIDS.

People who are on regular medication, though, dont stay that low for long. And if they do, they can still be healthier with a low T-cell count than someone with a higher T-cell count who is untreated.

HIV medication today is also simpler than ever. The standard is similar to birth control one pill a day at a similar time. And it can deliver such a high efficacy rate that someone can render their virus undetectable because there is so little virus in their bloodstream.

Thats a huge improvement in quality of life for people who feel that their HIV status isolates them from friendships or romantic relationships.

Like many people living on the street, however, Macht will never be able to manage his HIV like that.

Hopelessness or defiance has led him to resist treatment at times, which gave the virus an opportunity to take hold. Even when he has tried to take his medication consistently, it was been stolen while he stayed in shelters by people who thought the bottles held opiates or other pills that could produce a high.

Before landing in the hospital most recently, Macht said his medication had been stolen four times in a few months. That can make it impossible to stay on track, as most insurance plans will only pay to replace stolen medications about three times.

James Macht woke up feeling alone in the world, he said. The Portland resident, who has AIDS, says he's had an on again, off again relationship with his most recent girlfriend. November 5, 2019 Beth Nakamura/Staff

Treatment hard without housing

Macht is treated at the publicly funded Multnomah County HIV Clinic in Northwest Portland. The clinic is one of several that receives federal dollars to be innovative and meet more than just patients medical needs.

About 20% of the clinics 1,400 patients are homeless or, like Macht, are in and out of housing, said social worker and grant manager Emily Borke.

When an insurance company threatens to cut off Macht for losing his medications too many times, the county pharmacy will still refill the prescription perhaps in one or two-week doses instead of a full month so that if it is stolen again, there is less to lose. They can also put medications in bubble packs, which help some people better keep track of their pills, rather than rummaging through a backpack with their lifes belongings searching for the amber pill bottle.

But those solutions havent worked for Macht.

Those breaks in his prescription routine are dangerous, giving his virus an opening to beef up its defenses to the medication. Once the one-pill-a-day regimen stops working, treatment becomes more complicated. Multiple pills must be taken simultaneously, which means more pill bottles to be lost or stolen. Or, in the frantic cycle of packing and unpacking your stuff to shuttle between lines for the clinic, shelter and meals, two of the same pill could be taken at once instead of the required two different pills.

The more complicated the medication regimen, the more side effects. One of the most dire for people living on the street or in shelters is nausea and diarrhea. Without access to close and clean toilets and showers, the side effects can be embarrassing and inconvenient.

Thats where Macht has found himself. Lingering gastrointestinal problems make it almost impossible to put on enough weight to deal with his other impediments that make navigating a social service system even harder than the paperwork: Legs impaired by neuropathy, five teeth left to eat with, eyesight so poor its hard for him to read.

The countys HIV Clinic provides some relief. He has a case manager who picks him up in a taxi and rides with him to buy new pants or other errands. The clinic also hired a full-time housing specialist two years ago to help patients find shelter and then, permanent housing as soon as possible. She also tries to relieve the burden of a housing system that requires Macht to leave the hospital once a week to visit an office so he doesnt lose his spot on housing waitlists.

The clinics medical staff also spend a lot of time talking about patients priorities, which sometimes are not medical. They trouble shoot mental health issues, which also can get in the way of taking medication.

Still, for Macht, the lifestyle is so brutal on his immune system that when his health inevitably takes a turn for the worst, the clinic refers him to the emergency room.

On his way from his appointment at Multnomah County's HIV Clinic, James, left, ran into a friend. James, right, was too weak to climb the stairs to find a seat after hopping on the MAX train a few stops to his apartment.

Macht said he often feels stereotyped by ER staff who find out he doesnt have an address or know that a Bud Clark Commons address means he is homeless. He said he was turned away after brief exams several times in the last few months even as he dropped weight and infections took hold.

His primary care provider, Mary Tegger at the HIV Clinic, said hes probably right. Its endlessly frustrating for her to send her clients to hospitals to be admitted only to have them come back to her office the next week no better.

Some of Teggers patients are capable of keeping their HIV under control. But for those who are too scattered or sick, or too deep into addiction or depression to take medication, she said, they end up in a private health care system that stigmatizes homelessness and drug use or lacks resources to admit HIV patients.

Tegger said that Macht is a textbook case of why the HIV Clinic prioritizes housing and other social services for its clients. His T-cell count was in the double digits when he entered OHSU Hospital and would likely plummet back once he was discharged if he returned to a mat on the floor of a shelter.

His nutritional status is so poor, his immune system is so poor, so something like that could be the end for him because his body has so little to fight with, Tegger said.

Get housed or die

Macht left the hospital in mid-October. He spent four nights in a mens shelter and then moved into The Biltmore Hotel, a building managed by the homeless services nonprofit Central City Concern.

Normally a little grumpy, Macht was buoyant the day he moved in. A permanent home made him optimistic about the future. First, hed get glasses. Then new dentures. And then maybe, he said, hed sign up for college classes. He was looking forward to the future for once.

But just a week later, he began losing weight again. He left the hospital at nearly 150 pounds, but the constant shuffle to find three healthy meals a day had worn him down. He was back to 127 and dropping.

He told his doctor he was taking his multiple medications each day, but she knows that he has not always done so in the past.

Mostly, Macht is lonely. He tells people he meets that his HIV status makes him feel like a red jelly bean in a bag of blue ones. And as long as he is still able to infect other people, he feels too much guilt and shame to form new romantic relationships.

That stress didnt go away just because he found housing. He turned 42 last week, and knows going back to the street would make staying healthy impossible.

I dont care how good your diet is, how much you work out, Macht said, sitting on his bed in an otherwise empty apartment after the first night he slept there. Its going to get you. You got to take your medicine. Its like turning that hourglass with the sand. How big do you want yours to be? Small one, you run out of time fast.

You either get housed and take your medications, or you die.

James Macht leaves his apartment in downtown Portland to head to Sisters of the Road for a bite to eat. His building's elevator was not working that morning, making the three flights a challenge given his mobility issues. November 5, 2019 Beth Nakamura/Staff

-- Molly Harbarger | 503-294-5923 | @MollyHarbarger

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Low T Therapy After Prostate CA Surgery Appears Safe – MedPage Today

NASHVILLE -- Testosterone replacement remains controversial in men who have been treated for prostate cancer, but new data from New York's Memorial Sloan Kettering Cancer Center (MSKCC) reported here may provide some reassurance that "low T" treatments at least are safe in this population.

Among 1,563 men treated for high-risk prostate cancer at MSKCC and followed for up to 15 years, cancer recurrence rates were similar in men with low testosterone levels who took androgen replacement therapy to those in men with untreated low T and men with normal testosterone levels, reported Helen Bernie, DO, of Indiana University Health in Indianapolis.

And in a related study that included men with Gleason 6 and 7 prostate cancers, treated with radical prostatectomy, testosterone replacement begun 9 months after surgery showed no evidence of harm in ongoing follow-up (mean treatment duration of just over 3 years thus far), according to MSKCC's Carolyn Salter, MD.

Both studies were presented at the Sexual Medicine Society of North America's annual meeting.

"We believe that we have shown that testosterone therapy is not dangerous in these men, which has obvious clinical implications," said Salter, who added that -- given the absence of long-term safety data on testosterone treatment in prostate cancer patients -- larger and longer multicenter studies are still needed.

Bernie, who participated in the recurrence-rate study as a fellow at MSKCC, explained that it involved patients who underwent radical prostatectomy with high-risk prostate cancer, defined as Gleason 6/7 with unfavorable pathology, with positive surgical margins, lymph node involvement, and seminal vesicle involvement. Men with Gleason scores of 8 or higher with any pathology status were also eligible for recruitment. Biochemical recurrence was defined as a PSA level of 0.1 ng/mL.

Men were considered to have low testosterone if they had two or more morning blood test readings of less than 300 ng/dL.

In all, 1,119 (72%) men experienced biochemical recurrence at some point in 15-year follow-up, including 67% in the normal testosterone group, 80% in the untreated low T group, and 41% of men in the group with low T treated with replacement therapy.

After covariate adjustment, neither low T itself nor testosterone replacement therapy were associated with biochemical recurrence.

"These data suggest that patients with high-risk prostate cancer with low testosterone who were treated with testosterone therapy had no higher rates of biochemical recurrence," Bernie said.

Salter's study followed 360 men who have been prescribed testosterone therapy in the months following radical prostatectomy. To be considered for therapy, men had to have organ-confined disease and undetectable PSA post surgery. Men who opted for treatment had their testosterone doses titrated to achieve a serum level of 500-600 ng/dL, and PSA was checked every 6 months.

The men continue to be followed, and Salter noted that the mean time on testosterone therapy at last follow-up was 38 months. A single patient had a PSA recurrence, roughly 2.5 years after surgery.

Responding to an audience question after the presentations, MSKCC urologic surgeon John P. Mulhall, MD -- who helped establish the center's testosterone replacement therapy program more than a decade ago -- acknowledged that the treatment's long-term safety hasn't been completely established.

"We don't have enough data, but what we do have is a negotiated decision with our patients," Mulhall said. "We document in their chart that they have been made aware of the absence of long-term safety data, and that they accept that."

The researchers in both studies reported no funding source nor relevant disclosures.


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The Truth About Low Testosterone Levels, According to Experts –

Feeling tapped out. Foggy. Just not all that into sex. Gotta be your testosterone, ads would have you believe. And were believing it, too, with the number of T-supplement users tripling from the early 2000s through 2016.

Dont get us wrong: Testosterone is one critical hormone. Babies first encounter it in utero, when it triggers the differentiation of boys from girls. In puberty, it contributes to your bone growth and muscle mass, and continues to affect functions including your red-blood-cell production and mood stability.

But the message those ads are sending plays right into the economic and social anxieties men are facing. Its like when anti-anxiety meds such as Valium first came onto the scene, says urologist and MH advisor Elizabeth Kavaler, M.D. All these middle-aged women were addicted to Valium, because that was the solution to everything. Testosterone has become the new answer for a life of quiet desperation. More and more of us are feeling the exhaustion of uneasiness. We are being asked to do more with less. Were just trying to get through the day alive. Men think, Well, if I just get a little testosterone, Im going to feel great! Dr. Kavaler says. And thats not the case.

Theres so much information out there about Tmuch of it speculation and lorethat leads us to jump to conclusions about it. Men put all kinds of psychological weight on their testosterone numbera low one makes you think youre somehow less manly; a high one means youre basically LeBron Jamesand thats where we get things wrong. Theres little evidence for those stereotypes. Low doesnt automatically imply youre weak or retiring; high doesnt guarantee you muscles, aggressiveness, or MVP athletic performance.

A low number might not even be a low number for very long. It might just indicate that you havent been treating yourself very well. As long as your T is in the normal range, theres nothing about a high number thats better than a low one, or vice versa.

In the name of science and good journalism, I got my testosterone tested twice while writing this story. It put my assumptions up against a pretty big test, too (more on that later).

What do you really know about this famous hormone? Here, we break down the best and latest information to give you the clearest picture yet of what T means for you. And whether, maybe, you should be taking testosterone after all.

As many as 5 million men in the U.S. (generally older men) do actually have low levels of the hormone. To know if your testosterone is low, first see if you have any symptoms, which include: erectile problems, lack of energy (never feeling rested, no matter what you do; having a paunch; an AWOL libido (not just not wanting to have sex on a Thursday night after a crushing week, but lack of the kind of base-level sex drive wherein you get turned on by the sexy person you spot on the street, explains Tobias Kohler, M.D., of the Mayo Clinic).

With testosterone, as with life, normal is nuanced. And fraught (but shouldnt be). To get an accurate reading, you should have at least two tests, since testosterone is constantly in flux. It peaks in the morning, so if youre young and on a typical sleeping schedule, aim to be tested by 10:00 a.m. If youre over 50, it doesnt matter as much.

Be aware that your level can be affected by certain social factors and health habits. In the new book Testosterone: An Unauthorized Biography, scientists Rebecca M. Jordan-Young and Katrina Karkazis point out that T levels even respond to social factors like feedback. For instance, rugby players who watched video of good game plays and got positive feedback had up to a 50 percent increase in T compared with guys who were shown their mistakes and received critical assessments.

Resistance training can also give you a short-term boost in testosterone. Cardio doesnt elevate T levels as much in normal-weight men, says Jesse Mills, M.D., the director of the Mens Clinic at UCLA. But heres the thing: Jordan-Young and Karkazis dug through the research to find that T levels alone dont deserve the credit when it comes to an athletes performance. And cutting sleep short and taking multivitamins with biotin can push testosterone levels down (skip the vitamins for three days before testing).

So get your tests on days that are typical for you. And when you get your number, dont read too much into it. A T level of 264 to 916 nanograms per deciliter of blood is generally considered normal. If you are close to 264 and you feel fine, then youre no less healthy than a guy whose level is 700 and also feels fine. (Theres an exception to that, though: If your T level is below 300 and you have low-T symptoms, then docs would consider you in a low-T category)

Not reading into it is harder than it sounds. I got my first test at the tail end of a busy week. Id slept less than five hours the night before, then scrambled to the phlebotomist in a daze. My number: 287. Thats in the normal range, but just barely. I have no symptoms of low T, but it was hard to shake the feeling that there was something wrong with me, even though I know that normal is normal, no matter where it is in that range. Eleven days later, I was tested again. My number was 429. Why such a dramatic change? It might be because Id slept better and cut out my multivitamins.

Irrational or not, I felt like more of a man. The whole experience was a microcosm of our relationship with T. We act like its destiny, but its just biologyeasily misunderstood and more varied than we think.

The single best thing you can do to improve your level is be healthier. Avoid stress, get more sleep, and lose weightan enzyme in fat tissue converts testosterone to estrogen. Thats one reason flab can lower your T. Its also why overweight guys can develop man boobs, and why bodybuilders who juice can also develop man boobsthey dont have much fat, but theyve jacked their T levels so high that theres a lot of it available to be turned into estrogen. Thinking of T strictly as the male sex hormone oversimplifies the complex hormonal interactions that make our bodies work. Which is also why, if you can avoid it, you dont want to go with the needle-in-the-butt routine to raise your T.

But that might not work. If your level is low enough to warrant more aggressive treatment, your doctor can prescribe a drug that causes your pituitary to tell your gonads to make more testosterone. The typical choice is clomiphene citrate (Clomid), a common fertility drug for women. Using it doesnt exempt you from needing to get healthy, though, as it doesnt diminish the risk of losing T to bad sleep and a beer belly.

Then theres always testosterone-replacement therapy, which should be your last resort. (When you give your body T, it stops making its own, and theres no guarantee it can start again.) If, though, you and your doctor decide its the way to go, youve got options. You can try a testosterone replacement gel, a topical thats easy to use but can rub off on your partner or kids. There are pills, which are even easier to use than the gel and can deliver higher levels. Theres subcutaneous pellets, or rice-sized inserts that live directly under your skin. And then theres that needle in the butt, which can provide a major boost but is generally only used by docs who specialize in testosterone therapies.

Whatever you choose, be glad that weve moved past the early days of replacement therapies, like one in the 1920s that involved transplanting goat testicles into patients. Believe it or not, it didnt work, and it also didnt make anyone feel like more of a man.

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Is That Rash a Sign Your Treatment Isn’t Working? –

There are a wide variety of skin conditions that can occur in people living with HIV. It could be something as simple as a reaction to one of your meds, but it could also be a sign of a weakened or nonfunctioning immune system also known as immunosuppression. You should talk to your doctor right away about any significant skin changes or skin issues, as it could be a sign your medication isnt working properly. Here are the seven most common skin issues associated with HIV:

Molluscum contagiosum: A highly contagious viral skin infection that causes pink or flesh-colored bumps on the skin.

Herpes viruses: An outbreak of sores around the genital area or the mouth.

Kaposi sarcoma: A type of cancer that causes dark brown, purple, or red lesions on the skin, which often occurs in people with very low T cell counts.

Oral hairy leukoplakia: A viral infection that affects the mouth and can cause thick white lesions on the tongue that appear hairy.

Thrush: Also called oral candidiasis, thrush is a fungal infection that causes a thick white layer to form on the tongue or inner cheeks.

Photodermatitis: A condition in which the skin reacts to sun exposure by turning darker (much more so than a normal tan) and is most common in people of color. (Note: This is a common medication side effect and is not typically a sign of immunosuppression.)

Prurigo nodularis: Outbreaks of itchy, crusted lumps on the skin most common in those with extremely weakened immune systems as well as people of color living with HIV.

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Is That Rash a Sign Your Treatment Isn't Working? -

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Low T Specialist – Dallas, TX & Frisco, TX: Men’s T-Clinic …

What causes Low T?

Men may notice the effects of lower testosterone production after age 30. Additionally, Low T can be the result of primary testicular failure or a problem that originates in the testicles. Another cause of Low T happens in the pituitary gland the part of the brain that signals the testicles to produce testosterone. Low T can also occur as the result of an injury or infection.

Other factors that contribute to Low T may include:

Low T can present a variety of symptoms. Some of them mirror the symptoms of other medical problems as well, so its important not to ignore them. Seek treatment from a mens health care specialist if you have any of the following for more than a few days at a time.

The regulation and production of testosterone is the responsibility of the hypothalamus and pituitary gland. The body balances hormone levels when its functioning properly. For men with Low T, the body is either not signaling production effectively or it is not able to produce effective levels once it is given the signal to do so.

With testosterone injections, the hypothalamus and pituitary gland respond by signaling the testes to decrease natural production. Men who discontinue therapy revert back to their pre-therapy baseline testosterone levels. If those levels have been diagnosed as being inadequate, stopping the injections means you return to experiencing the symptoms you had before beginning treatment.

The only way to monitor your testosterone level effectively and identify potential issues is with multiple blood tests. This helps your doctor identify the proper dose specifically for you. No one likes to give blood, but the trained staff members at Mens T-Clinic make the process as painless as possible.

Testosterone production levels can vary, and a single blood test is just a snapshot of your bodys current production. Multiple factors can determine your level at any given time. For example, increases in the cortisol hormone (which increases with stress) have been known to lower testosterone.

Testosterone levels from 350 ng/mL to 1000 ng/mL are considered normal, but you could be in the low to normal range and experience symptoms.

Your doctor diagnoses hypogonadism by considering symptoms and testosterone levels. If you are borderline and have symptoms, you may qualify for therapy. Call or schedule an appointment online to learn about your options.

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Low Testosterone Therapy (TRT) and Treatment from Low T Center

Testosterone is a natural hormone responsible for the normal growth and development of the male sex organs and for maintenance of other sexual characteristics. In men, testosterone is produced in the testes (the reproductive glands that also produce sperm) and regulated by the hypothalamus and pituitary gland. With low levels of testosterone, men can experience a decrease in energy and libido, increase in body fat, and emotional changes.

A decrease in testosterone levels is to be expected as men age. Other factors can also contribute to low T, including chronic health issues such as diabetes or obesity, medications such as corticosteroids or trauma. Our comprehensive health assessment tests for low testosteronelevels as well as a multitude of other related issues and can be treated with customized, testosterone replacement therapy healthcare plans.

Its hard to pin down an exact number for exactly how common testosterone deficiency is among men. The condition becomes drastically more common as men age, and its estimated that as many as 40% of older men have low testosterone.

Many men, especially younger men, are nervous to seek treatment for low testosterone. While symptoms differ from person to person, men with low testosterone also experience a decrease in sex drive,erectile dysfunction, and heart disease. Waiting to seek help can lead to the late detection and worsening of these progressive conditions.

Low testosterone can result in a lack of energy. If you find that youre feeling sleepy for much of the day, even after youve had a good night of rest, theres a high chance that a hormonal imbalance is to blame. Many patients find that their energy levels soar after they begin testosterone therapy.

Testosterone encourages muscle growth. When men do not have enough testosterone, it can inhibit muscle growth. Muscle tissue burns calories at a higher rate than fat tissue. When men have low testosterone, it can result in fat gain, and for mostmen, that gain happens around the belly and hips. Sometimes, the imbalance of testosterone and estrogen can cause men to hold onto more body fat than they would otherwise.

Studies have shown that men who take testosterone tend to experience an increase in memory. Testosterone affects many physical processes in the body, and focus, clarity, and memory are no exception. Life issues caused by low testosterone- such as sexual and relationship issues- can also play a role in the struggle to focus.

While most men experience a decrease in sex drive as they age, low testosterone causes a steeper drop-off than what is normal for most men. Low testosterone can cause a variety of health issues (such as hair loss and erectile dysfunction) that may also inhibit sexual desire.

Low testosterone can result in a number of mood changes. Hormonal imbalances are often to blame for depression, anxiety, and other mood issues. Fatigue caused by low testosterone can also add to these issues.

Since testosterone is key for building muscle in the body, low testosterone can cause loss of muscle mass. This loss of mass can also add to fat gain, as previously mentioned.

Some men begin to lose hair as they age, andlow testosterone can also play a role, especially if the balding occurs suddenly.

See All Symptoms

By knowing your testosterone numbers, our medical professionals can provide quality treatment for low T and other underlying conditions. Your path to vitality happens with four steps:

By treating the symptoms of low testosterone, patients feel energized, stronger, and less irritable; enjoy more productive sleep and a renewed sense of self; find it easier to concentrate and remember; and experience an increase in libido.

Because Low T Center takes a holistic approach to mens healthcare, our medical professionals can proactively address other conditions youre currently experiencing or could experience later on, includingsleep apneaorallergies.These conditions may also affect testosterone levels.

Our providers get to know you on a personal level and gather important health data often to assess progress with greater efficiency.

At Low T Center, we focus on treating your symptoms of low testosterone levels, so you can rediscover the best version of yourself.

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Low Testosterone Therapy (TRT) and Treatment from Low T Center

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Low T Center – Men’s Health Clinic – Testosterone Replacement

Men's Clinic - What's Offered?

With little to no energy, you just cant function at times, and you certainly dont want to eat right or exercise. The lethargy could be caused by any number of health conditions such as obstructive sleep apnea, low testosterone levels, severe allergies, or even low thyroid.When men suffer from any of these conditions, poor lifestyle choices are made, especially when it comes to diet and exercise which can lead to more serious health problems down the road such as hypertension, high cholesterol, and diabetes. Lets gain control of your health issues before the conditions worsen.

The good news is you dont have to feel sluggish. Our mens health clinic staff at the Low T Center nearest you can quickly and easily determine what type of help is needed. We listen and learn about you, your symptoms, and your health goals. The combination of that knowledge along with a thorough analysis of your lab results will be used to prescribe a healthcare plan tailored to you.

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