testosterone replacement therapy · converts androstenedione and testosterone to estrogens...
TRANSCRIPT
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Testosterone Replacement Therapy
Steven Paletsky, M.D. Florida Specialists in Urology
No Speaker Disclosures
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Average Testosterone Level
AGE Average Testosterone Range Level under 25 692 376 - 1008 25-29 669 257 -1081 30-34 621 233 -1009 35 -39 597 219 - 975 40 - 44 597 201 - 993 45 - 49 546 190 - 972 50 -54 544 170 - 918 55 - 59 552 160 - 900
Where should we aim? 500 - 800
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Symptoms of Hypogonadism
Diminished Libido Erectile dysfunction Increased fatigue Difficulty in achieving an orgasm Decreased intensity of the orgasm Diminished sexual penile sensation Diminished energy, sense of vitality, or sense of well-being Depressed mood Diminished muscle mass & strength Diminished bone density Anemia Impaired cognition (?)
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Testosterone Replacement
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Testosterone Cost
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Replacement therapy
Excretion HALF - LIFE Testosterone Cypionate Urine 90%, Feces 6%, 8 days Testosterone Transdermal Urine 90%, Feces 6% 10-100 min
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Benefits of Testosterone
Reduce fat & Increase muscle
Improve your concentration
Maintain sleep & feel more rested
Maintain bone density/strength
Increase strength & athletic performance
Improve insulin sensitivity
Improve mood
Improve erectile function
Heighten your motivation
Increase sense of well-being
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Testosterone
Circadian rhythm - best taken between 7 to 10 AM
Draw fasting or with little food
Variation blunted with age ( can draw til 2 PM)
When to draw later in the day?
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Replacement
Can/Should you replace as a primary care physician? YES
How should you start? Baseline Free & Total testosterone CBC, CMP, PSA, DRE
Initial dosage? Testosterone cypionate 200mg/cc, 1/2cc IM, q wk (Receiving 100mg)
Follow-up? Free & Total testosterone after 3rd cycle (4 days post injection) Estradiol level? (breast tenderness?)
Should you treat if blood levels normal???
End point in treatment? Normal levels
When to stop? No benefit, cost, side effects (acne, aggression, etc)
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Monitoring Replacement Therapy
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Interesting Facts About Testosterone
High levels in females is an indicator of Polycystic Ovarian Syndrome
Testosterone increases level of Growth Hormone
Low T causes causes insomnia, sleep disturbances. Worsens sleep apnea
DHEA, Zn increases T
T converted to DHT harms hair follicles, causing baldness
T decreases fat mass, increases muscle mass, causes polycythemia
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Aromatase
Involved in production of Estrogen from Testosterone
Location - Adrenal, Ovaries, Testicles, Fat, Brain
Converts Androstenedione and Testosterone to Estrogens
Estrogens can not convert to Testosterone
Increase FSH & LH hormone, therefore increase Testosterone
Anastrozole - Aromatase inhibitor Side effects - Hot flashes, decr. sex drive, osteoporosis, myalgias
Clomid - an estrogen blocker, may incr. sperm count
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SHBG - Sex Hormone Binding Globulin
Glycoprotein that binds to androgens and estrogens
High levels indicate less total T
Increase levels seen in Liver dz and Hyperthyroidism
Produced in the Liver
Level decreases high levels of Insulin, GH, Prolactin, Androgens
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Adverse effectsCardiovascular - Evidence suggests neutral or beneficial effect Lipid levels - evidence suggests no change Erythrocytosis - 3-18% with transdermal 44% with injections Fluid retention - rarely seen Prostate enlargement - slow progression Prostate cancer - Probably not the cause, increases growth rate Hepatotoxicity - seen with oral replacement Sleep apnea - infrequent Gynecomastia - rare, reversible Skin reactions - 66% patch, 5% gels, rare with injections Acne - rare Testicular atrophy - can occur, especially in young men, reversible Infertility - usually reversible
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Contraindications
Breast cancer
Polycythemia?
Prostate cancer
Elevated PSA?
Desired fertility
Severe lower urinary tract symptoms
Uncontrolled CHF
Untreated obstructive sleep apnea
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The Future
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Questions?