Testosterone Replacement Therapy: Pros and cons

It has many functions and it is responsible for normal growth, development of the male sex organs and maintenance of the secondary sex characteristics.

Testosterone is also important for maintaining

• muscle bulk,
• adequate levels of red blood cells,
• bone growth,
• sense of well-being and
• Sexual function.

The production and secretion of testosterone is highly controlled by some other glands in the body and their hormones. The main controllers are definitely the hypothalamus and the pituitary gland. Hypothalamus is secreting Gonadotropin-releasing hormone (GnRH) which controls the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) produced by the pituitary gland. 

1. Luteinizing hormone regulates the production and secretion of testosterone by the Leydig cells of the testes, and
2. FSH stimulates spermatogenesis.

Another important fact is that females have a low level of testosterone. It is being produced by the theca cells of the ovaries, by the placenta, as well as by the adrenal cortex, in both sexes.

Testosterone effects on human

Prenatal effects:

• Genital virilization  
• Development of prostate and seminal vesicles

Early postnatal effects:

• Adult-type body odor
• Increased oiliness of skin and hair, acne
• Axillary hair
• Accelerated bone maturation

Advanced postnatal effects:

• Increased libido and erection frequency
• Pubic hair extends toward umbilicus
• Facial hair
• Chest hair
• Subcutaneous fat in face decreases
• Increased muscle strength and mass
• Deepening of the voice
• Growth of the Adam’s apple
• Growth of spermatogenesis tissue in testes, male fertility
• Shoulders widen and rib cage expands
• Completion of bone maturation and termination of growth.

Causes of testosterone deficiency?

Testosterone deficiency results from the testes being unable to produce the normal levels of testosterone.
This deficiently can be physiological or pathological. Physiological deficiency occurs with age. As a man ages, the amount of testosterone in his body gradually declines. This natural decline starts after the age of 30 and continues throughout the life.
In healthy male population 20–40 years of age, the level of early morning testosterone should be 21.8 nmol/L (627 ng/dL).

Pathological deficiency is caused by some other condition and the most common causes are:

1.    Injury or infection of the testicles
2.    Chemotherapy or radiation treatment for cancer
3.    Genetic abnormalities such as Klinefelter's Syndrome
4.    Hemochromatosis caused by too much iron in the body
5.    Dysfunction of the pituitary gland (a gland in the brain that produces many important hormones)
6.    Inflammatory diseases such as sarcoidosis  
7.    Medications, especially hormones used to treat prostate cancer and corticosteroid drugs
8.    Chronic illness
9.    Chronic kidney failure
10.    Liver cirrhosis
11.    Stress
12.    Alcoholism

What Are the Symptoms of Testosterone Deficiency?

Testosterone deficiency has many effects on the body. The most common effects of the testosterone deficiency on man are:

• Decrease of sex drive
• Erectile dysfunction
• Feelings of depression
• Decreased sense of well-being
• Difficulties with concentrating

There are also several other changes that occur in the body such as:

• Decrease in muscle mass, with an increase in body fat
• Changes in cholesterol levels
• Decrease in hemoglobin and possibly mild anemia
• Fragile bones (osteoporosis)
• Decrease in body hair

Primary testicular failure is causing a condition called hyper-gonadotropic hypogonadism. In this condition testosterone levels are low and pituitary gonadotropic hormones are elevated.

In secondary or hypogonadotropic hypogonadism, there is a decreased secretion of pituitary gonadotropic hormones.

• Pre-pubertal hypogonadism is characterized by infantile genitalia and lack of virilization,
• Hypogonadism after puberty results in a diminished libido, erectile dysfunction, infertility, gynecomastia, impaired masculinization, changes in body composition, reductions in body and facial hair, and osteoporosis.

Testosterone Deficiency

Symptoms   

• fatigue
• lethargy
• depression
• impotence
• loss of libido
• muscular weakness
• decreased shaving frequency 

Signs   

• loss of body, facial and pubic hair
• gynecomastia (increased breast tissue)
• smooth, fine wrinkly skin, especially face
• reduced testicular volume   

Long Term Risk

• Osteoporosis can occur in untreated patients, leading to increased risk of hip and spine fractures.

Testosterone replacement therapy

Who are the best candidates for testosterone replacement therapy? Men should only be treated if the blood tests show low level of testosterone. The average male produces 4-7 mg of testosterone per day in a circadian pattern. Evaluation of potential candidates for testosterone replacement therapy should include a complete medical history and hormonal screening. When the blood testosterone levels are normal, it means that treatment will not help in relieving the symptoms. Men with the primary hypogonadism are best candidates for testosterone replacement therapy. Men who have prostate cancer or breast cancer should not take testosterone replacement therapy. Successful management of testosterone replacement therapy requires appropriate evaluation and an understanding of the benefits and risks of the treatment. Legally, the use of testosterone to improve athletic performance or correct short stature is potentially dangerous and inappropriate.

There are many pros and cons of this treatment. It is proven that several symptoms can benefit significantly from this therapy. Some of those are:

• Low sex drive
• Problems with erections
• Reduced muscle mass and bone density
• Depression

Testosterone could be applied several ways!

What is the ideal hormone replacement therapy? Well, it is the therapy that produces and maintains physiological serum concentrations of the hormone stabile without significant side effects.

Injections

This is the most effective way of testosterone application. The hormone is injected directly into the muscle and patient should know that there are several possible side effects. The most common are pain from the injection, and a change in energy level, mood and sex drive.

Transdermal patches

It is best when these patches are applied to the skin on testicles, but, they can be applied almost anywhere on the body. They are very easy to use. They don’t cause any disadvantages accept maybe local skin irritation.  The non-scrotal patch, known as Androderm, is meant to be worn on the arm or torso.

Gel

Gel, known as Androgel, is applied to the skin once a day. It has one disadvantage only - it is really expensive!

Benefits of testosterone replacement therapy

There are a number of benefits of testosterone replacement therapy that have been demonstrated and evaluated. It has many positive effects on mood, energy levels, and libido.
Transdermal testosterone replacement therapy particularly has been linked to positive effects on fatigue, mood, and sexual function, as well as significant increases in sexual activity.
Positive effects on body composition are also evidenced, as well as the improvements in bone density. These effects are usually noted within 3 to 6 weeks.

Disadvantages and risks of testosterone replacement therapy

There are several risks of testosterone replacement therapy and every patient should be familiar with all of them, before starting the therapy. The most serious side effects that may occur are:

Increase of the red blood cells count

For patients with anemia or low blood count, this could be beneficial but it can be potentially dangerous for a healthy individual.This is because too many blood cells can block the blood vessels and lead to a heart attack or a stroke.

Prostate effects

It is proven that testosterone therapy increases the volume of the prostate gland. But there are no researches saying that testosterone therapy increases the risk of prostate cancer. That’s why, if you have an enlarged prostate, a condition called benign prostatic hyperplasia, testosterone is contraindicated because it may worsen your symptoms. If you have a history of prostate cancer, you cannot receive testosterone therapy.

Skin reactions

They are the most common side effect when a patch is being used! This can be avoided by using gels and injections!

Infertility

This is common in young men that receive the testosterone therapy, but usually reversible after the therapy stops.

Sleep apnea

This is a very serious condition in which breathing is being disrupted during sleep. Although it isn't so common, it has been reported.

Fluid retention

Patients with history of heart failure or kidney disease should be careful.

Laboratory abnormalities

There are several laboratory abnormalities that can occur with hormone replacement and the most common are:

• Changes in cholesterol concentrations.
• Decrease in sperm count producing infertility

Other possible side effects

Acne, oily skin, breast enlargement, increased body hair and flushing have also been reported.

Lipid Abnormalities

Physiologic testosterone replacement is known to reduce total cholesterol, low density lipoprotein (LDL), and high density lipoprotein (HDL) levels.  These elevations can cause significant increase in blood viscosity.