By Lee Ann Boyd, Certified Urology Nurse Practitioner
It is estimated that 2.5 million men over age 40 have hypogonadism – or low testosterone. The discussion of low testosterone often gets controversial when it comes to managing it – who do you treat? How do you treat it? What type of follow up is necessary? What are the risks of testosterone therapy?
Testosterone levels in men vary greatly with a range of 300-1,050. The occurrence of low testosterone increases with age but low levels may be due to multiple factors. To name a few – genetic causes, testicular trauma, pelvic radiation, cancer-treating drugs, abuse of alcohol or recreational drugs, use of opiates for chronic pain and many other chronic diseases can contribute to low testosterone.
Complaints may include decrease in sex drive or sexual performance, decrease in muscle strength and muscle mass, decrease in bone density, decreased energy, change in sleep patterns and mood changes. Some of these symptoms may be vague and can also be contributed to other conditions, such as depression and thyroid disorders. Therefore, it is very important that the patient share information about their medical history, and current and past medications with their healthcare provider.
Patients being evaluated for low testosterone should have at least two morning blood testosterone levels with consistently low values. Men must also have significant symptoms to warrant testosterone replacement therapy (TRT).
Recent data has shown an increased risk of blood clots, stroke and cardiovascular events in those being treated with TRT. However, further studies should be done to evaluate if these patients had very elevated levels of testosterone in their blood on their current treatment. Clinically, we have seen patients on TRT referred to us for continuation of care, with baseline testosterone levels much higher than recommended. If the blood becomes too thick, it will be reflected in the hematocrit blood values. In this instance, a patient may have therapeutic phlebotomy to lower the hematocrit levels. As prevention, some healthcare providers recommend a daily dose of baby aspirin. There is often careful screening for men who have had a blood clot, stroke or heart attack within six months. A cardiology referral may be deemed appropriate to assess a man’s cardiovascular risk before initiating TRT.
There is little data to suggest that testosterone replacement therapy causes prostate cancer, however, testosterone can cause progression of an underlying prostate cancer. It is essential that patients have a baseline rectal exam and prostate specific antigen (PSA) study prior to TRT, and every 6-12 months thereafter. The patient should discuss with the healthcare provider if there is a family history of prostate cancer.
It remains unclear if TRT may cause worsening of untreated obstructive sleep apnea and difficulty urinating. Use caution if these conditions exist, and monitoring for progression of symptoms is important. Patients should be aware of a decrease in sperm count while on TRT, which may be impactful in the child-rearing-age patient. Breast tenderness or enlargement should be reported to the healthcare provider.
Testosterone replacement therapy may take many forms. It is available as a nasal gel, topical gel or patch, an immediate release as well as a slow-release injection, and implants placed under the skin. For those patients who choose topical therapies, care must be taken to prevent these products from coming into contact with children or pregnant women. Follow the product recommendations closely.
Hypogonadism can drastically effect a man’s quality of life. Many men have concerns about lack of intimacy in their relationships. They may have little “get-up-and-go,” which can negatively impact their job performance, sleep cycles, mood and overall energy level. A thoughtful discussion with your healthcare provider is essential before starting TRT. Reasonable expectations of treatment should be reviewed, and the patient should be monitored frequently for improvement in overall symptoms as well as possible adverse reactions to treatment.
Lee Ann Boyd, MSN, ARNP, is a certified Urology Nurse Practitioner at Mission Urology.