When
Should Testosterone be Used to Treat Erectile Dysfunction:
Safety vs. Effectiveness?
For many
decades testosterone replacement therapy has been utilized to
initially treat many men with erectile dysfunction. When should
men be treated with testosterone? Is it safe? What form of testosterone
should be used? And how should it be followed.
Testosterone
replacement definitely should be used in men who have a deficiency
in their male hormone levels (androgen=testosterone), occasionally
in those males who have borderline low levels of testosterone
and probably never used in men who have normal or elevated levels
of androgen.
Approximately
two to 20 percent of males with erectile dysfunction have definite
low levels of androgen requiring testosterone replacement therapy.
Besides poor sexual function they also have poor desire and
lack of sexual interest. On the other hand, men who have normal
testosterone levels with erectile dysfunction run very significant
risks if they add additional androgen to their body including
higher risk of stimulating prostate cancer, greater chance of
lower urinary tract obstructive symptoms due to stimulation
and benign growth of the prostate gland, increased blood coagulation
with a higher incidence of thromboembolic disease (clots) and
coronary artery disease, chemical hepatitis especially if taking
the oral mentholated testosterones and possibly a higher incidence
of cancer of the liver.
Therefore,
these serious complications of androgen replacement although
occurring very infrequently are so severe that one must seriously
consider using testosterone in patients with borderline or normal
testosterone levels. On the other hand in those patients who
have definite low levels of testosterone associated with erectile
dysfunction more frequently androgen replacement does resolve
the ED, improve sexual desire and interest and in reality allows
the patient to have a normal level of male hormones, not a supernormal
level. Making individuals producing normal levels of testosterone
in ED patients logically would improve all aspects of sexual
function however, desire interest almost always improves but
function probably becomes normal in only 50 percent of these
patients. Other forms of impotence therapy such as Viagra maybe
necessary to bring erectile function to a normal situation for
the patient. In addition, even though a patient maybe deficient
in his male hormones he may also have other problems such as
vascular decease, diabetes, neurological problems that still
make up a major component in the production of ED.
The major
question in determining whether a male has low testosterone
is based upon blood levels usually obtained in the morning since
the a.m. levels are approximately 35 percent higher than the
p.m. levels. In most patients the morning levels are greater
than 300 nanogram/DL. However, one must take into consideration
the age of the patient as well since as one gets older the serum
binding goblins increase making for less free testosterone which
is the bioactive form. Therefore, a young male less than 40
years of age with a level of 300 is really abnormal while a
70 year old man with a 300 level is probably normal. The laboratory
test and the level of testosterone alone is not sufficient to
determine whether one has a low testosterone and has to be viewed
in terms of the age of the patient and the history and physical
examination. A borderline level with small testes is much more
suggestive of a truly pathologically low level especially if
it is associated with poor desire. One must also look at total
testosterone in relationship to the non-protein bound free or
bioactive form, the hormones produced by the pituitary gland,
gelatinizing hormone and follicle stimulating hormone as well
as prolactin, a hormone produced by the base of the brain connected
to the pituitary gland.
Approximately
3 percent of all testosterone deficiencies are due to elevated
prolactins which are usually due to microscopic growths in the
pituitary gland or brain stem and can be resolved with specific
drugs such as Parvati. In rare cases if the lesions are quite
large surgery maybe necessary. The LH is frequently elevated
in those patients in which the testicle is the source of the
testosterone failure and in those cases in which the testosterone
is due to a failure of the pituitary gland the LH may be low.
For most patients however the hormones are all normal with the
exception of testosterone and the pituitary testicular access
is intact except that the testicles cannot produce enough testosterone,
pituitary hormones are either normal or elevated and the prolactin
itself is basically normal.
This being
the case and having determine that the patient is testosterone
deficient how much, how often and what type testosterone should
be given to the patient. Firstly, the oral form of testosterone
which is frequently a mentholated form should never be given
to patients on a chronic basis since liver toxicity is quite
high and can be dangerous. Injections of testosterone in the
form of testosterone enanthanate or cyprionate have been the
standard form of administering testosterone. Two hundred milligrams
intramuscular every two to three weeks seems to give sufficient
levels to help most men who need hormonal replacement. On the
other hand, injection therapy and injection replacement with
testosterone gives you a rapid rise in 24 to 48 hours and a
continuously high level that drops slowly over the course of
10 to 14 days. Normally, the testosterone is higher in the morning
than it is in the afternoon by 35 percent and no one is quite
sure whether replacing by reproducing this diurnal variation,
is the effectiveness of the testosterone better in ED.
Therefore,
patches containing testosterone manufactured either in the form
of Andoderm 5 g. or Testoderm (TTS) 5 g. have been developed
to reproduce this diurnal variation. The patch is placed on
the fleshy portions of the body including the thigh, abdomen,
chest, back but not on the bony prominences. It is placed at
night giving its highest levels in the morning and its lower
levels in the late afternoon and evening. Each night the 5 gram
patch is removed and replaced in a different area with a new
patch. The levels remain high but highest in the morning.
Recreating
the normal diurnal variation occurs and possibly improvement
in erectile dysfunction also happens. The major drawback of
the testosterone patches has been skin irritation which with
andro is as high as 50 percent and Testoderm as high as 15 percent.
Use of a topical steroid placed in the center of the patch such
as triancininolone seems to reduce the incidence of local irritation,
swelling and in the most severe cases blister formation. On
the other hand, patch therapy is simple, does the job and maintains
a diurnal variation in testosterone levels.
Once one
starts therapy a life long treatment regime is necessary and
follow up by the physician should be done on at least a six
month to one year basis. Prostate screening with digital rectal
exam and PSA blood testing must be done before within three
months of beginning therapy and at six to twelve months thereafter.
Basically
liver function tests should also be done on an annual basis.
If the ED is not significantly improved then blood levels of
testosterone should be obtained in the morning after six to
twelve weeks of therapy to see if there is sufficient levels
of testosterone levels in the blood and if necessary a second
patch, increased dosage, or more frequent injections should
be considered. If adequate levels of hormones are reached and
the patient still does not have optimal erectile function the
patient should be reevaluated for another etiology and other
therapy such as Viagra, Prostaglandin injections or intraurethral
Prostaglandin pellets should be seriously considered along with
the continue use of andro replacement.
by
Myron I. Murdock, M.D., FACS
Medical Director, hisandhershealth.com
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