🔑 Key Takeaways
- Dr. Khera discusses common male sexual health concerns and treatments, providing accessible information for those looking to improve their understanding of sexual health.
- Sexual health involves multiple systems, and conditions like erectile dysfunction and sexual dysfunction can impact both men and women, leading to emotional distress and relationship issues. Seeking medical care is crucial for a holistic approach to sexual health.
- Patients experiencing sexual dysfunction should not be embarrassed to discuss it with their doctors as diagnosing ED can be as simple as asking two questions. VENT can be used to identify underlying causes, and sex therapy including daily Tadalafil can treat psychogenic ED.
- Medications like Viagra work by blocking phosphodiesterase which would eat up cyclic GMP- the active component that maintains an erection. Different medications have different levels of side effects due to their varying cross-reactivity with phosphodiesterases.
- Atrophy and fibrosis of the muscle due to aging can cause erectile dysfunction. Increasing blood inflow through drugs, tourniquets, or consistent use of sexual organs can help. Hormone replacement therapy may benefit women's sexual health in particular.
- Regular use of low-dose Cialis can effectively prevent muscle atrophy and maintain healthy penile tissue, while also treating BPH and pulmonary hypertension at an affordable cost. Choose a quality generic with caution.
- Sexual function is influenced by age-related hormonal changes but can be improved with lifestyle modifications. ED can indicate cardiovascular disease, highlighting the importance of overall health for sexual wellbeing.
- ED can be a warning sign of underlying cardiovascular disease. Lifestyle modifications and diagnostic tests can improve endothelial function and identify hemodynamic problems. Early diagnosis and management of cardiovascular disease can prevent ED and improve overall health.
- Peroni's Disease is caused by trauma during intercourse, resulting in an abnormal curvature that affects sexual activity. Treatments include Collagenase and anti-inflammatories. Penile prosthesis may be necessary in severe cases, and immediate medical treatment is required for penile fracture.
- Traction devices like the Restorex can reduce the curvature, increase length and width of the penis, and shorten the healing process. Using it consistently for three months can offer optimum results.
- Catching ED early on during the active phase can prevent further ED progression. Stretching device treatment and ultrasound results can inform treatment decisions, while injection therapy is an option for some.
- Multiple treatment options are available for ED, including pills, injections, and a penile implant. Injection requires careful dosing to avoid priapism, while a penile implant is safe and effective with risks that can be minimized by choosing an experienced surgeon.
- To reduce infection risk, prophylactic antibiotics, limiting movement, and short operative time are essential. Catching infections early with strong antibiotics is crucial, and prompt treatment for priapism and timely penile implant insertion is critical for optimal outcomes.
- Priapism, a rare but serious side effect of certain medications, requires immediate medical attention. Treatment involves injecting an antidote and removing sluggish blood and clots. Regular use of certain medications can increase the risk of complications, but injecting opposite sides every other day can help reduce this risk. If an implant is needed, it's important to let the tissue calm down first to avoid potential complications.
- Shockwave therapy is a potential treatment for ED that recruits stem cells, helps with nitric oxide synthase, and brings in neo-angiogenesis. While class type three machines like Gaines Wave can be effective, they don't work in all patients, and more research is required. Beware of treatments that may take advantage of ED patients who are vulnerable.
- Patients should be cautious of advertised ED treatments and seek FDA-approved options. Stem cell therapy for ED has short-lived effects and not FDA-approved. Exosome therapy may be a promising alternative with more research needed.
- Ejaculatory dysfunctions, particularly premature ejaculation, are common but often go untreated. Diagnosis includes ruling out psychogenic factors and classifying as lifelong or acquired. Although stem cells, PRP, and exosomes show potential, shockwave therapy is the most promising. Seeking help and treatment is important, and there should be no stigma attached to taking available drugs.
- Premature ejaculation is a common sexual dysfunction caused by various factors. While medication may help initially, sex therapy can provide long-term benefits by teaching patients techniques to prolong ejaculation and addressing underlying stress.
- Medications like SSRIs and alpha blockers can treat premature ejaculation and delayed orgasmia, but may have side effects like addiction and retrograde ejaculation. The squeeze method can also be effective, while reducing SSRI dosages can improve ejaculatory latency time.
- Treating ED can be a way to tackle the root cause of premature ejaculation. Testosterone replacement therapy involves a complex hormonal interplay with levels indicating production or obstruction issues. Controlling estrogen and DHT conversion with inhibitors is not recommended.
- Free testosterone, not total testosterone, is the better indicator for low testosterone symptoms. Calculated free testosterone is more accurate than assays. SHBG levels affect free testosterone and increase with age, genetics, comorbid conditions, and obesity. The body compensates for testosterone fluctuations by adjusting SHBG levels.
- When considering testosterone replacement therapy, it's important to look beyond just the numbers and consider symptoms, muscle mass, bone mineral density, and potential long-term effects like fertility issues. Patients should be fully informed about risks and benefits before starting treatment.
- There are several methods to increase testosterone, such as clomiphene, HCG, and injectable testosterone, each with its own benefits and drawbacks. The best treatment choice depends on one's preferences and situation.
- HCG and microtesi are effective options for testosterone replacement therapy in pituitary patients. Medications can raise testosterone levels in Klinefelter syndrome patients with infertility, but fertility should be prioritized. Monitoring testosterone doses is critical for prolonged use.
- While HCG can protect access during testosterone use, it doesn't boost production. Natesto is a commercial option that doesn't suppress sperm production, while FSH is more effective but pricey. Illicit testosterone use is tempting but seeking medical help is important to avoid potential adverse effects.
- Testosterone can be administered through injectables at an affordable cost and with minimal pain. Consult with an endocrinologist to determine the type and frequency of the injection. Patients can choose the injection site that works best for them.
- Different forms of testosterone medication are available such as oral, injectable, and pellet forms. Oral medications should be taken with a meal for proper absorption, while pellets require a physician to implant them and prohibit exercise for 72 hours post-insertion. Injectable forms require regular administration but are popular for their autopilot nature. Patients should work with their physician to determine the best form of testosterone treatment that suits their lifestyle and needs.
- Injectable testosterone therapy is more effective, convenient, and cost-effective than topicals. Aim for upper quartile total testosterone levels for optimal physiological outcomes, as the current definition of hypergonadism is not reliable for well-being.
- Customizable TRT based on a patient's androgen receptor assay and free testosterone could be more effective than blindly increasing testosterone levels. Understanding genetic variability in androgen receptor sensitivity can help prescribe appropriate treatment, avoiding potential negative effects of medication.
- Finasteride can cause irreversible sexual and neurological symptoms in some patients, which may not be recognized as drug side effects. Blocking steroid conversion can lead to depression, anxiety and cognitive decline and even increase the risk of suicide.
- Patients taking medications for BPH or alopecia should be warned of potential side-effects like sexual dysfunction and depression. Testosterone replacement therapy does not increase prostate cancer risk and may decrease hypogonadism risk.
- Recent trials show testosterone therapy could protect against prostate cancer and improve cardiovascular health. Bipolar androgen therapy may convert castrate-resistant prostate cancer to castrate sensitive, offering a cost-effective alternative to standard care.
- High doses of testosterone can decrease prostate cancer growth, but low doses may increase it. Castration or normogonadal range treatment is preferable over hyper-gonadal range treatment, and informed decision-making is necessary when undergoing radical treatments.
- Testosterone replacement therapy with aromatase blockade may offer a therapeutic option for breast cancer in women, despite controversy around using aromatase inhibitors. Consult with an oncologist and consider the Sexual Men's Society of North America for provider options.
📝 Podcast Summary
A Discussion on Male Sexual Health with Dr. Mohit Khera
Dr. Mohit Khera, a professor of urology at Baylor College of Medicine, speaks about male sexual health, including erectile dysfunction, Peroni's disease, penile fractures, premature ejaculation, delayed orgasms, testosterone replacement therapy, and the role of testosterone in patients with prostate cancer. The conversation also covers DHT and finasteride, and some of the concerns around post-finasteride syndrome. This podcast aims to translate the science of longevity into something accessible for everyone, providing the best content in health and wellness. It is a great resource for those interested in taking their knowledge of sexual health to the next level.
Understanding the Complexity of Sexual Health
Sexual health is a complex issue as it involves the confluence of three different systems- urinary, reproductive and sexual. Erectile dysfunction (ED) is a prevalent condition that affects 52% of men over the age of 40, and this percentage keeps increasing with age. However, it is not just aging that causes ED but also the acquisition of comorbid conditions. Sexual dysfunction is not just exclusive to men; women, too, suffer from it. Still, the insidious nature of these disorders makes people suffer in silence, leading to depression, anxiety and impaired quality of relationships. Therefore, it is crucial to recognize them as a holistic system and seek medical care when needed.
Barriers to Discussing Sexual Dysfunction with Doctors and Diagnosing Erectile Dysfunction with Simple Questions
Approximately 40% of men surveyed had some degree of sexual dysfunction, but only 51% of those men told their doctor about it. Clinicians do not ask about it, and patients are embarrassed to ask about it. To diagnose ED, just two simple questions need to be asked: Are you able to get an erection sufficient for penetration? And are you able to maintain that erection until orgasm? VENT is the mnemonic for the ideologies that cause ED, which are vascular, endocrine, neurologic, trauma, and medications. Psychogenic ED is treated with sex therapy, which may include daily Tadalafil at five milligrams. Young patients are more likely to have psychogenic ED, which can be differentiated from organic ED by asking questions about morning erections and masturbation.
How medications like Viagra work to maintain an erection
Erections are induced by parasympathetic nerves that secrete nitric oxide, which causes an increase in cyclic GMP. Phosphodiesterase eats up the cyclic GMP, leading to a lost erection. Medications like Viagra and Cialis work as phosphodiesterase inhibitors to block the loss of the cyclic GMP and maintain an erection. Different medications have varying levels of cross-reactivity with phosphodiesterases, leading to certain side effects. Avanaphyl has the least cross-reactivity, but it is still not generic. Viagra was originally developed as a blood pressure medication and failed as a systemic reducer. However, it unintentionally became a highly successful treatment for erectile dysfunction.
Understanding the Root Cause of Erectile Dysfunction in Aging Men and Women
Aging can cause venous leak, which leads to inability to keep blood in the penile tissue resulting in erectile dysfunction. The root of the problem is atrophy and fibrosis of the muscle which can be overcome by increasing the inflow of blood. There are several ways to increase inflow like using Viagra or intra-cavernoso injections. Another way is to use a tourniquet to compress the veins and still allow inflow. However, these drugs have more impact on men than women. HRT treatment probably has the greatest impact on women's sexual health, especially as they age. Prevention of atrophy of the muscle can be increased by consistent use of sexual organs.
Importance of Daily Cialis in Post-Prostatectomy Recovery
Regular use of the penile muscle is important to prevent muscle atrophy after prostatectomy. Nocturnal erections provide oxygen to the penile tissue, and daily PD-5 inhibitors like Cialis can help with hypertrophy of the cavernosal smooth muscle and keep the tissue healthy. Daily Cialis is also FDA-approved for BPH and pulmonary hypertension. Five milligrams of daily Cialis, which is very affordable, produces the same tissue level as 8 milligrams taken on demand. Patients can also get 90 pills of Cialis for $17 with no insurance, and generics are not significantly less effective than the brand. However, caution should be exercised in choosing a quality generic brand.
Age-related changes affecting male sexual function and ways to improve it
Age-related changes in male physiology, including refractory time and ED, are influenced by hormonal changes. Prolactin levels after ejaculation may be implicated in the refractory period, but age also affects the ability to have erections. Quality of health is an important factor in maintaining sexual function, regardless of age. Lifestyle modifications, including diet, exercise, sleep, and stress reduction, can improve erectile function. ED can be a leading indicator of cardiovascular disease, with a strong correlation between the risk factors for both conditions. Therefore, improving overall health can have a positive impact on sexual function and overall wellbeing.
Erectile Dysfunction and Cardiovascular Disease: Understanding the Common Link
Erectile dysfunction (ED) can be a warning sign of cardiovascular disease. Studies have shown that 15% of men who developed ED had a cardiovascular event within seven years. Endothelial dysfunction is the common link between ED and cardiovascular disease. Lifestyle modifications such as diet and exercise can improve endothelial function and reverse ED. Diagnostic tests like ultrasound and injection of medications can help identify hemodynamic problems in penile tissue including arterial insufficiency and venous leak. Diastolic velocity greater than 5 millimeters per second indicates venous leak which is the number one cause of ED. Early diagnosis and management of underlying cardiovascular disease can help prevent ED and improve overall health.
Peroni's Disease: Causes, Symptoms, and Treatment Options
Peroni's disease is usually born of trauma that occurs during intercourse, and it causes an abnormal curvature that can make intercourse prohibitive. In 2015, the first FDA-approved treatment for Peroni's disease, called Ziaflex or Collagenase, came out. Patients with the disease suffer greatly, experiencing depression and disfigurement. Anti-inflammatories are the only medication that is indicated for Peroni's disease. There is an active phase and a quiescent phase for Peroni's disease. If patients have erectile dysfunction with Peroni's disease, a penile prosthesis can be inserted. Penile fracture is a break in the tunica albigenia and requires immediate medical therapy.
Treating Peronis with Traction Devices
Peronis, a condition that causes an abnormal curvature of the penis, affects 7-9% of men and is associated with pain during erections. Low testosterone levels can increase the risk of injury and impair the healing process. While surgery is an option, traction devices like the Restorex can also be effective in reducing curvature and increasing length and width of the penis. Traction devices work by constantly stretching the penis, making it more pliable, and must be used consistently for at least three months for optimal results. The Restorex is unique in that it can bend in the opposite direction of the curvature, shortening the time needed to wear the device.
Detecting and Treating Erectile Dysfunction
Detecting and treating erectile dysfunction (ED) during the active phase is better than during the quiescent phase. Stretching device treatment, while off-label and expensive, can prevent further ED progression during the active phase. Ultrasound results can identify the type and severity of ED, informing treatment decisions, such as offering a band for venous leak. Low peak systolic velocity in the penis may indicate cardiovascular risk. Injection therapy is a potential ED treatment option, but eligibility and duration of effectiveness varies depending on factors such as age and overall health.
Treatment options for Erectile Dysfunction (ED)
There are multiple treatment options available for ED and the approach should involve shared decision making with the patient. The options include pills, injections, and a penile implant. Injection is an effective treatment option, but it should be done carefully as the dose is dependent and higher doses can lead to priapism. Penile implant is a safe and effective treatment option for ED and involves a surgical procedure to place cylinders inside the penis that can be inflated with normal saline by a small pump in the scrotum. The surgery has some risks, but it is relatively safe when performed by an experienced surgeon.
Mitigating Risks in Penile Implant Surgery
The risk of infection in penile implant surgery is mitigated by several measures in the operating room, including the use of prophylactic antibiotics, limiting movement in the room, and ensuring short operative time. The infection rates are generally low, but prosthetic infections can be serious and require the use of strong antibiotics like Vancomycin and Gentamicin. It is important to catch infections early, or else the implant may have to be removed. In the case of priapism, patients must seek medical attention within four hours to avoid irreversible damage, and a penile implant must be inserted within three months for optimal outcomes.
Understanding and Treating Priapism: A Comprehensive Guide
Priapism is a rare side effect of medications like trazodone, cocaine, and phosphodiesterase inhibitors that cause an erection that won't go down. If an erection lasts for more than 4 hours, it is recommended to go to the ER. Treatment involves injecting an antidote like fennel effrin, aspiration irrigation, or a T shunt to remove sluggish blood and clots. However, there is a risk of developing venous clot or peronies, especially when trimax is used regularly. Injecting opposite sides every other day can reduce this trauma. It's essential to let the tissue calm down before putting an implant, as a shunt can cause arterial to venous connection leading to a high flow that is treated differently.
Shockwave Therapy for ED Treatment: Focal vs Radial Shock.
Shockwave therapy, through inducing trauma, has shown to improve the condition of ED by recruiting stem cells, bringing in neo-angiogenesis and helping with nitric oxide synthase. Machine types are divided into those that have a focal shock and those that have a radial shock. The radial shock is less penetrating and is of low-pressure. It is classified as a type one medical device, low risk, and can be purchased by anyone. The ED population is vulnerable to treatments, making them susceptible to being taken advantage of. Off the sugar pill, 30% of men will get the best directions of their life through the placebo effect. While more research is required, class type three machines like Gaines Wave can be effective, but they don't work in all patients.
Potential Therapies for Erectile Dysfunction
There are potential therapies for treating Erectile Dysfunction (ED) including low-intensity shockwave therapy, electromagnetic therapy by Stortz, and stem cells. However, these therapies are not FDA approved, and more studies are needed to prove their efficacy. Patients should be cautious about advertisements promoting ED treatments that make unbelievable claims. Stem cell therapy for ED is not a lasting effect and needs a placebo control trial to provide insight. Also, exosomes may be the next way to treat ED. However, more research is needed in this area. Patients who want to acquire stem cell therapy for ED need to go outside the country as it is not FDA approved.
Understanding and treating ejaculatory dysfunctions in men
Ejaculatory dysfunctions are common among men, with up to 30% experiencing some degree of it. Premature ejaculation is more prominent, affecting up to 30% of men. However, only 9% of men seek therapy for ejaculation problems. Two ways to classify premature ejaculation are lifelong or acquired, and the patient must have three variables. One of which is a decreased ejaculatory time, usually less than two minutes for lifelong cases. Stem cells, PRP, and exosomes show potential in treating erectile dysfunction but lack scientific evidence, with shockwave being the most promising. There is a need to rule out psychogenic factors before proceeding to pharmacologic treatment. Men should seek help and not suffer in silence, as there should not be a stigma attached to taking available drugs that can help their condition.
Understanding premature ejaculation and its treatment options
Premature ejaculation can be a lifelong or acquired condition, and the patient must be bothered by it, have a loss of control, and experience a decrease in time. Biological, neurobiological, genetic, and psychological factors can contribute to premature ejaculation. Treatment options include lidocaine sprays, SSRIs, and sex therapy, with medication as a second-line therapy. Stress can have a significant impact on all forms of sexual dysfunction, and patients suffering from it are recommended to undergo therapy. While pills may offer a quick cure, sex therapy is a more effective solution in the long run and can teach patients techniques to prolong ejaculation.
Treating Common Sexual Disorders: Medications, Techniques, and Side Effects
Premature ejaculation (PE) and delayed orgasmia are common sexual disorders treated with medications like SSRIs and alpha blockers. PE can also be treated with techniques like the squeeze method, which delays ejaculation. However, medications like tramadol can lead to addiction and should be used with caution. Retrograde ejaculation, which occurs when semen goes into the bladder instead of the urethra, is a common side effect of alpha blockers and can impact reproduction. Delayed orgasmia is typically a side effect of SSRIs, and reducing the dosage can improve ejaculatory latency time while still providing benefits for depression. There are no FDA-approved treatments for delayed orgasmia. The average time for ejaculation is six to seven minutes, but it varies by country and culture.
Addressing ED as a Step to Delay Premature Ejaculation
Treating ED first can also help delay premature ejaculation by addressing the underlying psychological factor of losing an erection. Testosterone replacement therapy involves a complex interplay between GNRH, LH, FSH, testosterone, SHBG, and DHT, with negative feedback loops from testosterone and estrogen. Small testicles with elevated FSH and LH indicate a production problem, while normal levels and no sperm indicate an obstruction problem. Some clinics attempt to control estrogen and DHT conversion using aromatase inhibitors and five alpha reductase inhibitors, but this is not recommended by the speaker.
Measuring free testosterone levels accurately
Free testosterone is the best indicator to measure symptoms of low testosterone, rather than total testosterone levels. SHBG is equally split with albumin and only 2% testosterone is free in the body. Calculated free testosterone is more accurate than the assay for estimating free testosterone levels. Age does not affect total testosterone levels significantly but the SHBG levels increase with age, which lowers the free testosterone levels. Genetics, comorbid conditions, and obesity affect SHBG levels. SHBG plays a crucial role in maintaining hormone hemostasis and the body compensates for fluctuations in testosterone levels by adjusting SHBG levels.
Considerations for Treating Low Testosterone Levels
While plasma concentration of free testosterone is valuable information, it is important to consider how much of the free testosterone actually enters the cell and how many androgen receptors are present. Symptoms and other factors, such as muscle mass and bone mineral density, should also be taken into account when deciding whether or not to treat low testosterone levels. It is important to not just focus on the numbers but also how the patient feels. Avoid treating patients unnecessarily and consider the long-term effects of testosterone replacement therapy, including potential fertility issues. Patients should be informed about all potential risks and benefits before starting any form of testosterone replacement therapy.
Different ways to boost testosterone levels and their pros and cons.
There are several ways to raise testosterone levels, including using clomiphene, HCG, and injectable testosterone. Clomiphene is a pill that preserves both testicular volume and spermatic function but may decrease libido and sexual function in some men due to its negative feedback effect on the estrogen receptor. HCG is an injectable that mimics LH and preserves testicular volume but is expensive, delicate, and requires refrigeration. Injectable testosterone is a common choice but comes with its own set of pros and cons. Recently, there has been a run on clomiphene due to a national backorder and the inability to compound HCG. Overall, the choice of treatment may depend on individual preferences and circumstances.
Treatment Options for Pituitary Issues, Klinefelter Syndrome, and Testosterone Replacement Therapy
For patients with pituitary issues, HCG can be an expensive but effective option to bypass the pituitary and go straight to the testicle to increase testosterone. Clomid may not work in patients with elevated LH and FSH initially. XXY chromosome condition, known as Klinefelter syndrome, results in infertility, and sometimes gynecomastia and delayed development. Medications can raise their testosterone levels, however, testosterone might not be the first option unless fertility is not an issue. Microtesi is a procedure that can be used to help these patients have children. Patients on testosterone should monitor their doses, and physiologic doses are the recommended choice for prolonged use. Vigilance is recommended when using testosterone.
HCG and other options for maintaining sperm production during testosterone use.
HCG can protect access when testosterone is being used but it alone doesn't boost endogenous production. Studies have shown that 500 units of HCG every other day can help maintain sperm production with a decline in some patients only. The intranasal testosterone, Natesto, showed no significant suppression of spermatogenesis and is commercially available. Recombinant FSH is the better choice to improve fertility but is very expensive at about $500 a month. Men may opt for illicit testosterone rather than seeking medical help due to its cheap availability. Clomiphene can also help maintain sperm production but can cause adverse effects due to estrogen problems.
Administering Testosterone for Hormonal Imbalance
Testosterone can be administered through various means like pellets, topical gels, injectables and more. Injectables offer a quicker onset of effect and are affordable with a cash price from a compounding pharmacy at $25 per month. The injections should be made on Sundays and Thursdays in subcutaneous tissue using a 25 gauge, short needle, five-eighths inch, one CC syringe. Pinching the fat helps decrease the pain and injectables have no significant suppression in spermatogenesis. An endocrinologist must decide based on age between Cipionate and Ananthate. Zeyst is a popular option but comes at a considerably higher cost of $150. Patients prefer the belly area for the injections, but it can be done wherever they feel comfortable.
Types and Administration of Testosterone Medications
Oral testosterone medications are becoming popular due to their ease of administration, but they have to be taken with a meal to ensure proper absorption. Three oral testosterone medications are now FDA approved and available. Injectable and pellet forms of testosterone are also available, but they require more active management. Pellets provide stable testosterone levels for three months, but require a physician to implant them and no exercise is allowed for 72 hours post-insertion. Injectable forms of testosterone require regular administration but are popular for their autopilot nature. Patients should work with their physician to determine the best form of testosterone treatment for their individual situation and lifestyle.
Injectable Testosterone Therapy vs Topical: A Comparison
Injectable testosterone therapy is preferred over topicals and has better physiological outcomes with lower erythrocytosis rates. Absorption of topicals varies and can be affected by factors such as skin condition, hair, and exfoliation, making it less effective. Injectable therapy is also more convenient and cost-effective. Testosterone has different effects on different body parts and sensitivity levels vary, making it important to aim for the upper quartile for total testosterone levels. The current definition of hypergonadism at 300 nanograms per deciliter is not a reliable indicator of well-being as many patients at lower levels may feel good.
Personalized TRT Based on Antigen Receptor Sensitivity Could Lead to Better Treatment Decisions
Sensitivity of the antigen receptor determines the response of patients to different doses of treatment. Customizable TRT based on a patient's androgen receptor assay and free testosterone could lead to better decisions. DHT plays an important role in sexual function and hair growth. 5-alpha reductase inhibitors, such as finasteride and dutasteride, affect numerous parts of the body, including the brain and adrenal glands, and can have detrimental effects. Personalized treatment based on a patient's receptor sensitivity could be more effective than blindly increasing testosterone levels. It is important to understand the genetic variability in androgen receptor sensitivity among patients to prescribe the appropriate treatment.
The Dark Side of Finasteride: A Close Look at Post-Finasteride Syndrome
Finasteride, a drug used for treating alopecia and BPH, has been linked to irreversible sexual and neurological symptoms in a subset of patients, known as post-finasteride syndrome (PFS). While the official position of the American Urologic Association on PFS is unclear, less than 5% of men experience negative side effects according to the package insert. However, Mohit Khera believes that the actual percentage could be higher than 5% and many men mistakenly attribute the symptoms to aging, especially if they take the drug at a later age. Blocking the conversion of steroids, including progesterone, to their neurosteroids can result in depression, anxiety, and cognitive issues, thereby increasing the risk of suicide in some individuals.
Study Needed to Understand Alarming Suicide Rates Among Patients on Certain Drugs
The alarming rate of suicide among patients taking certain drugs needs to be studied through randomization or post-hoc analysis. The drugs, like finasteride, that are associated with depression need to be given more attention. Men who take medications for BPH or alopecia should be warned of the potential side-effect of sexual dysfunction and depression. The occurrence of sexual side-effects even after stopping the medication may be due to epigenetics and needs further study. Testosterone replacement therapy does not increase the risk of prostate cancer and may actually decrease the risk of hypogonadism, although it may increase the incidence of high-grade prostate cancer. Exogenous testosterone therapy does not lead to an increase in atherosclerotic cardiovascular disease.
The Benefits of Testosterone Therapy for Prostate Cancer and Cardiovascular Health.
Recent studies suggest that testosterone may not only be safe, but it may also protect against the development of prostate cancer. The Traverse Trial, the largest of its kind, aims to evaluate the effect of testosterone on cardiovascular health in men. Bipolar androgen therapy (BAT) may convert the castrate-resistant prostate cancer to castrate sensitive, and high doses of testosterone may not only improve the quality of life but also increase overall survival. The cost of enzalutamide, the standard of care for castrate-resistant metastatic prostate cancer, is $8000 a month compared to $100 for 400 milligrams of testosterone. More attention needs to be given to the Transformer Trial, which suggests that using bipolar endotherapy and then enzolutamide could increase survival in such cases.
Testosterone and Prostate Cancer Treatment
High doses of testosterone lead to a decrease in prostate cancer growth, while low doses lead to an increase. Castration helps decrease the growth of prostate cancer but undergoing chemical castration can lead to negative side effects such as metabolic derangement and a poor quality of life. To treat prostate cancer, castration or normogonadal range treatment is preferred over hyper-gonadal range treatment. Consent forms must be signed to undergo radical treatments and informed decision-making is necessary. The prostate saturation model states that once testosterone levels reach 250 nanograms per deciliter, PSA levels plateau and do not continue to increase with higher testosterone levels. There is currently no data to support that testosterone causes breast cancer.
Testosterone Replacement Therapy with Aromatase Blockade for Breast Cancer
Testosterone replacement therapy with aromatase blockade may be a therapeutic option in women with breast cancer as it is protective against breast cancer. However, the use of aromatase inhibitors is a controversial topic. The studies have shown that giving testosterone without an aromatase inhibitor is still protective. It is important to note that many treatments are used with oncologists consultation. The Sexual Men's Society of North America is a great organization to find a provider in a specific area either through telemedicine or via in-person visits. The majority of doctors in the organization are in academic institutions.