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Nagalli does not report any relevant financial information.
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Testosterone deficiency – defined by the American Urological Association as testosterone levels of 300 ng / dL or less – occurs in up to 39% of middle-aged and older US males, data from translational andrology and urology show.
Although interest in the disease is growing among health professionals, understanding of it is not the case, experts said.
“Testosterone tests and prescriptions have nearly tripled in recent years,” write the authors of the American Urological Association’s 2018 guidelines on testosterone deficiency. “However, it is clear from clinical practice that there are many men who use testosterone without a clear indication.”
Shivaraj Nagalli, MD, FACP, an internist at Shelby Baptist Medical Center in Alabaster, Alabama, said in an interview that testosterone deficiency was one of the most “misunderstood issues” among general practitioners and internists.
We asked in connection with the men’s health month Nagalli to discuss common misconceptions about testosterone deficiency, risk factors for the disease, treatments, and more.
Healio basic care: What are some common misjudgments about testosterone deficiency by internists, general practitioners, and general practitioners?
Nagalli: The first misjudgment is that a random one-off screening is indicated for men aged 65 and over. However, the ACP and the European Society of Endocrinology advise against routine screening for hypogonadism in asymptomatic men.
A second misconception is that all low testosterone men need testosterone therapy. It’s important to remember that testosterone levels drop 1% to 2% every year as you age. For this reason, routine screening is not recommended and not all patients diagnosed with low testosterone levels need to be treated.
Testosterone deficiency may be due to a problem in the testicles (primary hypogonadism) or secondary hypogonadism elsewhere.
Regardless of the type, symptoms of hypogonadism such as fatigue, lack of energy, and insomnia are not entirely due to lack of testosterone. Therefore, the more common causes of these symptoms must be ruled out before proceeding with testosterone replacement. It’s also important to note that testosterone levels fluctuate throughout the day, peaking around 8 a.m. Therefore, it is best to measure these values between 8 a.m. and 10 a.m. should fast before checking these values.
Healio basic care: What are some of the Risk Factors for Testosterone Deficiency?
NagalliObesity, chronic alcoholism, and chronic use of opioids, anabolic steroids, and gonadotropin-releasing hormone analogs are some of the risk factors for low testosterone levels. Testicular torsion, testicular trauma, and a history of pelvic radiation therapy can also lead to testosterone deficiency.
Healio basic care: Are there certain foods that contribute to testosterone deficiency? Which? How strong is the club?
Nagalli: There is limited evidence that foods like tofu and other soy-based products, processed foods, liquorice, and those with polyunsaturated fats lower testosterone levels, as does chronic alcohol and opioid use. Additionally, fried foods were linked to low testosterone levels in a study in patients with chronic kidney disease.
Healio basic care: Which condition (s) are men with testosterone deficiency at higher risk of developing?
Nagalli: Low testosterone levels can lead to low energy levels, a decrease in libido and muscle mass, fractures with little impact trauma, gynecomastia, and loss of armpit and pubic hair. Poor concentration and memory problems as well as insomnia are possible. If the testosterone deficiency is due to primary hypogonadism, then infertility may also be present.
Healio basic care: How should doctors treat testosterone deficiency in primary care? What are the risks associated with the treatment?
Nagalli: Management begins by confirming the diagnosis and evaluating its cause.
First, family doctors need to assess the clinical significance of low testosterone levels. Are the patients symptomatic? Does the patient have a constellation of symptoms such as decrease in libido and muscle mass, fractures with little impact trauma, gynecomastia, loss of armpit and pubic hair? Once the testosterone deficiency is confirmed, the next step is to check the LH, FSH and prolactin levels and refer the patients to an endocrinologist. These patients also need a brain MRI to check for a prolactinoma.
Lifestyle changes are recommended to treat testosterone deficiency. In addition, testosterone can be replaced via transdermal routes (e.g. testosterone gels) and parenteral routes (e.g. testosterone enanthate or testosterone cypionate). The choice of therapy depends on patient preferences, costs, and insurance coverage.
Once a pharmaceutical approach has been taken, an assessment of the continued need for that drug should often be made. Testosterone levels should be checked every 2 to 3 months until the level has stabilized, with the goal of getting about halfway between 300 ng / dL and 900 ng / dL in all men except older men. In elderly patients, slightly less than half is more appropriate due to the risks associated with testosterone substitution.
The use of testosterone substitutes is associated with risks for hypercoagulability, thromboembolism, CVD (myocardial infarction / exacerbation of heart failure), and prostate cancer. There is also a risk of spermatogenesis suppression.
Healio basic care: What is the ACP’s position on testosterone therapy? How do the guidelines of other professional societies differ? How can doctors reconcile these differences?
Nagalli: ACP advises that men with age-related low testosterone may experience slight improvements in sexual and erectile function from testosterone replacement and therefore this treatment may be considered. However, it is not recommended to prescribe testosterone for men with less specific symptoms such as energy, vitality, physical function, or cognition.
The Endocrine Society suggests offering testosterone on an individual basis to older men who have symptoms and signs of testosterone deficiency and who, after explicitly discussing the potential risks and benefits, consistently and clearly have low serum testosterone levels.
The selection of candidates for testosterone therapy should be made for each patient individually by evaluating the risks of testosterone substitution in a detailed discussion between prescribing physicians and their patients.
References:
Anaissie J. et al. Translated Androl Urol. 2017; doi: 10.21037 / tau.2016.11.16.
Mulhall JP et al. J Urol. 2018; doi: 10.1016 / j.juro.2018.03.115.
Unified healthcare. June is the month of health for men. https://www.unicityhealthcare.com/mens-health-month-bringing-awareness-mens-health-issues-month-june/. Retrieved June 18, 2021.
Urology Care Foundation. Men’s Health Month. https://www.urologyhealth.org/media-center/mens-health-month. Retrieved June 18, 2021.
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source https://dailyhealthynews.ca/proper-testosterone-deficiency-therapy-starts-with-correct-diagnosis/
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