of the initial evaluation, a determination is made whether T replacement is indicated. The goal of T replacement, at least from a wellness and preventive medicine perspec- tive, is to get the blood levels of free T to the high end of normal for a healthy 25-30 year old. This distinction is critical—normal does not mean optimal. A free-T level of 50 may be in the normal range, but it pales in com- parison to the optimum range of 170-220. “But testosterone declines as we age.
Isn’t that normal? Why should we mess with nature?” These are frequent questions. There are two schools of thought regarding hor- mone replacement. Conventional medicine holds that hormone levels decline because we age. Preventive medicine, on the other hand, maintains that we age because our hormones decline! This is a subtle but pow- erful difference. (A related counter-argument is: Eyesight naturally declines as we age, and we also develop cataracts. Yet medicine routinely treats these. The same is true for hearing loss. Why is a double standard ap- plied when it comes to hormones?)
Testosterone Replacement: Topical or Injectable
Topical is the most common and most
convenient. While there are commercially available topical testosterone creams and patches (Androderm®, Androgel®, Testim®), they are generally insufficient to raise T levels to the optimum range. This is because they contain only 1% testosterone. Custom compounded testosterone creams, on the
other hand, can contain 10%, and even 20%, testosterone. Topical application has the advantage
of being convenient and painless. However, there are significant considerations. Because men metabolize T rapidly, creams ideally should be applied every 12 hours to main- tain adequate levels. Not all men can consis- tently maintain this dosing schedule. Creams should not be applied immedi- ately before intimate contact or within 2-3 hours of going to bed, to prevent contami- nating your partner. This is especially true if your partner is pregnant; testosterone in pregnant women can cause birth defects. You also need to be extremely careful of physical contact with babies and young children within 2 hours of application, to avoid transfer.
About 10% of people will not absorb medication well through the skin, so creams do not always work. And in 1-2% of men who use creams, there is an increased risk of hair loss. This is because the testosterone in the skin can be converted to dihydrotes- tosterone (DHT), one of the main causes of male pattern baldness. Testosterone cream is best applied to the inner aspect of the forearms, and the arms are rubbed together to distribute the cream. An alternative site is the upper inner aspect of the thighs (being careful to avoid contact with the genitals). T cream should NEVER be applied to the belly. This is because of the high concentration of estrogen receptors in the belly fat that will convert the T into more estrogen.
Injectable T is therefore an option for some men. Believe it or not, the self-admin- istered injections are virtually painless in most cases! Injectable T avoids many of the pitfalls of topical, especially the contamina- tion concerns. The best application method is to inject a small amount daily under the skin. This maintains consistent levels throughout the week. More common, but less ideal, is once or twice weekly injections into the muscle. However, this results in a large spike in levels, and then the levels drop off quickly, so there is a yo-yo effect. Subcutaneous injections are most easily
given in the front of the thigh. You pinch or grab a wad of skin to pull it away from the underlying muscle, and inject under the skin. Like the cream, never inject into the belly. I prefer to use insulin syringes for injection. Their small needles and small size make for easy dosing and painless injection.
Oral Forms: Least effective and increase the risk of liver toxicity.
Over-the-counter products marketed
to raise T levels are largely ineffective. In young men (under 40) who are still produc- ing relatively normal T levels, some of these products may have a very slight benefit. But above 40 they are generally a waste of money.
Many wellness physicians add an ingredient called “chrysin” to their T cream prescription. Chrysin inhibits the natural conversion of testosterone to estrogen. They mistakenly believe that estrogen in men is harmful. The opposite is actually true. Men need estrogen, and, except in the case of certain heart disease, there is absolutely no scientific evidence that estrogen is harmful. Estrogen protects against bone loss, reduces the risk of Alzheimer’s disease, and protects against coronary artery disease. Blood serum T levels should be mea-
sured every 4-6 weeks, and the dose adjust- ed as needed to reach and maintain optimal levels. Then labs can be checked every 6-12 months. Cholesterol (including total, HDL, LDL, triglycerides), PSA (prostate), and other labs also should be checked periodically.
Side Effects
Side effects are rare with T replacement. Hair loss (with topical use), injection site irritation, fluid retention, and gynecomastia (breast enlargement) can occur, but these are very rare and easily treated.
14 Natural Nutmeg June 2012
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