Men also often report an improvement in mood from testosterone replacement. Whether these effects are barely noticeable, or a major boost, is highly individualized.
The common preparations of testosterone replacement have frequent, mild side effects. Testosterone side effects most often include rash, itching, or irritation at the site where the testosterone is applied.
Testosterone replacement so far seems to be generally safe. Experts emphasize that the benefits and risks of long-term testosterone therapy are unknown, because large clinical trials haven't yet been done.
Over time, the testicular “machinery” that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism (“hypo” meaning low functioning and “gonadism” referring to the testicles). Studies have shown that testosterone-replacement therapy may offer a wide range of benefits for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing. The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these “soft symptoms” as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity usually does not go along with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, it’s more of a challenge to get a good erection.
How do you determine whether a man is a candidate for testosterone-replacement therapy:
There are two ways that we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no symptoms.
Traditionally, anti-androgen medications have been used in combination with LHRH agonists to block testosterone. When anti-androgens are used alone it is called anti-androgen monotherapy. This approach is attractive for some men because it causes in a milder degree of testosterone blockade with less side effects. There are three anti-androgen agents - Casodex, Flutamide, and Nilutamide. They work by keeping testosterone away from the androgen receptor, an enzymatic "switch" inside the prostate cancer cell. This switch stimulates cell growth when it's turned on. Anti-androgens keep the switch in the "off" position. Because anti-androgens do not eliminate testosterone altogether, they have fewer side effects than the LHRH agonists such as Lupron, Trelstar, Eligard and Zoladex.
Clinicians with experience using Casodex monotherapy estimate that Casodex monotherapy is about 70% as effective as the LHRH agonists but with only 30% of the toxicity. Anti-androgens have been studied in prospective randomized trials as stand-alone therapy and combined with radiation. Overall, compared to LHRH agonists, side effects are certainly less. And compared to placebo, they clearly retard prostate cancer growth. The only caveat with Casodex monotherapy is a higher risk of breast growth. This can be partially or completely prevented with prophylactic breast radiation or an estrogen blocking pill called Femara.
Whenever the action of testosterone is inhibited, side effects ensue--hot flashes, osteoporosis, loss of muscle and loss of libido are typical. Many other side effects can also occur. Casodex monotherapy is less likely to induce muscle loss and less likely to reduce libido than the LHRH agonists. For example, only about 50% of younger men lose their libido whereas about 80% of men lose their libido with LHRH agonists.
There is one side effect that is more common with Casodex monotherapy than with LHRH agonists - breast enlargement. The medical term is gynecomastia. Gynecomastia occurs in 10% to 20% of men treated with LHRH agonists and in 50% to 60% of men on AAM. Gynecomastia can be prevented with radiation or an estrogen blocking pill called Femara. However, once breast tissue develops, it can only be removed with liposuction or surgery. To be effectively prevented, the radiation or the Femara must be started prior to starting treatment.
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