Testosterone Replacement Therapy
Optimization to Young Adulthood Levels
Testosterone Replacement Therapy is not a miracle, but many patients (both men and women) report that it helps build muscle, improve sex drive, reduce body fat, and restore more youthful energy levels. Testosterone Replacement to young adulthood levels may stimulate cells of various tissues to produce the enzymes which control metabolic process, that would otherwise diminish with age. Thus, maintaining Testosterone levels at physiologically optimum levels may help maintain cellular vitality, tissue strength and function, and slow the progression toward some of the various degenerative conditions of aging.
The optimal serum testosterone level for aging men is unknown. But, we do know that men are strongest, most virile, and healthiest when they are young, and that vitality fades with age. The entire suite of hormones (Testosterone, DHEA, Melatonin, Growth Hormone…) are at their peak in youth, and wane with age. Thus, the correlation between youthful hormone levels and health, strength, and enthusiasm is a reasonable hypothesis.
But, the vitality of youth is probably due to more factors than hormone level. Many other factors can contribute, such as: attitude, lifestyle, diet/nutrition, stress, exercise, and heredity. Hormone repletion cannot fully overcome a health-negative lifestyle. Thus, hormone repletion must be engaged as a piece of the puzzle. But, having acknowledged its limitations, it is a very important piece. To use an automotive analogy, hormones are like a key; a car may be well fueled, lubricated, well designed, and smoothly balanced in all its components, but without the key, without turning on the cellular machinery, the cells produce no output.
The experience of many clinicians and their clients gives evidence to the fact that strength returned, and the symptoms of many age-related illnesses receded upon commencing Testosterone Replacement Therapy (especially when administered as a part of a full BHRT hormone replacement therapy program, including: DHEA, Thyroid, Growth Hormone, Melatonin, Vitamin D, Pregnenalone, Oxytocin – plus Estrogen & Progesterone for women…).
And, as with any medical intervention, there is a sweet spot, a middle level of intervention that is “just right”. From clinical experience, we know that repleting a man’s testosterone levels to the level of young adulthood will often allow him to retain and regain a measure of the power of youth. But, if the levels are raised too quickly, the body may not be accommodated to the new function and strength of these testosterone-sensitive tissues.
The question really is, “Should men try to change the normal decay of their health with age?” Possibly the decay with age is part of God’s plan, and we should not interfere with that divinely ordained pattern. But, it may also be that the aging and decay is part of the curse that came with the fall of man, and it is not God’s will at all.
In short, we don’t know for certain whether or not we should be replace hormones at all. As a physician, my duty is to remove suffering and to do no harm. But, being realistic, it is impossible to only remove suffering and never do harm. There is always the risk of harm when making an intervention – the future is uncertain. I can only advise of the risks and benefits – each individual must decide how much he risk he/she is willing to take compared to the benefits that might result. ***
Some bets are easy to make, because they involve a very high probability positive outcome, and a very very low probability negative outcome. The more the probability gap narrows, between benefit and negative outcome, the more uncertainty arises, since people consider the risk more likely to actually occur.
A more realistic way of looking at the risk/benefit probabilities of Testosterone Replacement (than how much the risk increased) is to look at the absolute numbers. How many people actually got benefit, and how many people actually suffered a negative outcome?
Should we supplement Testosterone at all? Should we interfere with the normal progression of the passage from birth to death? Will there be an automatic natural cost, a decay, a natural loss of This might be possible if we could find a person who had not suffered the ravages of the degradation of programmed cell death (i.e. due to telomere shortening) and the toxic insults of modern life (pesticides/herbicides, heavy metal pollution, food additives, drugs, mineral-depleted soils/foods, and stress…). But, since such perfection cannot be found, we are thus forced to use reason as to the optimal levels of Testosterone (and all other hormones for replacement therapy).
Thus, since Free Testosterone is at its peak at young adulthood; and, on a population average, it drops gradually over time to a low level in old age; and, the vitality of youth wanes generally with the reduction of Free Testosterone; and, the replacement of Testosterone restores many of the abilities, passions, and attitudes of younger life; it appears that Testosterone Replacement Therapy to the levels of young adulthood is a reasonable theory to pursue, especially when begun while still healthy.
To this end, practitioners have observed clinically that when men are repleted to a level of testosterone equivalent to young adulthood, that the therapy is both well tolerated, and the patient experience is satisfying. Since the body has its highest function in young adulthood, repletion to this level seems appropriate; especially since without replacement, the decay in strength, function, and/or enthusiasm proceed predictably with age.
The advantages/benefits of Testosterone Replacement Therapy (TRT) are obvious for the man who is frankly hypogonadal. (The conventional definition of hypogonadal is: total testosterone below the laboratory reference range. But, functionally hypogonadal is waking without a morning erection, gaining weight around middle, and not putting on muscle when doing a significant workout.)
The majority of aging men are not hypogonadal as per the laboratory norms for their age group, but nearly every man at some point, after 40/50/60/70 is functionally hypogonadal. For every man in this group, there is also clear benefit in restoring their testosterone levels up toward the levels of high normal young adult levels.
The benefits are clear, but the immediate question is what is the cost? What is the risk? Is there any potential for harm with Testosterone Replacement Therapy?
In general, the answer is, “No, there is no harm with TRT.” But, such an answer must be qualified. If the patient has Prostate Cancer, then repletion with testosterone is not advisable, since prostate cancer can grow in the presence of testosterone. It is for this reason that men with Prostate Cancer are typically given testicular resection (surgical or chemical).
For this reason, a PSA test is administered to get an idea if prostate cancer may be present. If the reading is modestly high (2.6 or over), then a Free PSA is administered to see if further indication of prostate cancer is present (over 25% then probably BPH, under 10% probably Prostate CA). The PSA is checked monthly at each follow up lab test until optimal levels are achieved, and then yearly at each annual evaluation of hormone levels.
Testosterone can be administered as an injection, topical cream, or subdermal inplant. I prefer the cream, because of the small variation in the level – keeping the free Testosterone at close to the optimal throughout the whole month. (Caution: you need to apply early morning, late night, so kids and wife do not get in contact with the cream for 4 hours after application.)