Will Taking Testosterone Lower My Sperm Count

Will Taking Testosterone Lower My Sperm Count

World J Mens Health. 2019 Jan; 37(1): 45–54.

Testosterone Is a Contraceptive and Should Not Be Used in Men Who Desire Fertility

Amir Shahreza Patel

¹Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

Joon Yau Leong

²Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA.

Libert Ramos

¹Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

Ranjith Ramasamy

¹Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA.

Received 2018 May 4; Revised 2018 Jun 22; Accepted 2018 Jul 1.

This article has been cited by other articles in PMC.

Abstract

Testosterone has a variety of functions and is commonly used in older men to treat symptoms of hypogonadism, such as decreased libido, decreased mood and erectile dysfunction. Despite its positive effects on sexual function, it has a negative effect on fertility. Exogenous testosterone therapy can negatively affect the hypothalamic-pituitary gonadal axis and inhibit the production of follicle stimulating hormone and luteinizing hormone. The purpose of this review is to discuss the contraceptive properties of testosterone therapy and to discuss strategies to increase testosterone in men with the desire to preserve fertility.

Keywords: Contraception, Family planning services, Hypogonadism, Infertility, Testosterone, Testosterone replacement therapy

INTRODUCTION

Testosterone is a pleiotropic hormone that plays various physiological roles in the development of male genitalia in utero and during puberty. Classically, testosterone is a hormone associated with masculinity. Testosterone is used as treatment for males with late onset hypogonadism, a condition in men who experience symptoms caused by a decrease in serum testosterone. Symptoms associated with low testosterone can include decreased libido, decreased muscle mass, depressed mood and/or erectile dysfunction. The use of testosterone replacement therapy (TRT) among men over the age of 40 years has increased more than 3-fold over the last decade [1].

Exogenous testosterone comes in various preparations and each form carries various risks. Along with an increase in hematocrit, a major adverse effect of TRT is the diminished sperm production because of the decreased intra-testicular concentration of testosterone and suppression of the hypothalamic-pituitary-gonadal (HPG) axis [2,3,4]. Suppression of follicle stimulating hormone (FSH) release from the pituitary gland impairs sperm production and suppression of luteinizing hormone (LH) release inhibits intra-testicular testosterone production.

The purpose of this review is to evaluate the contraceptive effect of testosterone, discuss how the use of exogenous testosterone can negatively impact a man's fecundity and identify the importance of family planning in men who are planning to receive TRT.

PHYSIOLOGY OF TESTOSTERONE

In healthy adult men, testosterone production is precisely regulated by the HPG axis. Higher cortical centers in the brain signal the hypothalamus to secrete gonadotropin-releasing hormone (GnRH) in a pulsatile fashion. GnRH in turn stimulates the release of LH and FSH from the anterior pituitary which modulates testosterone production from the Leydig cells and spermatogenesis by the Sertoli cells, respectively. As testosterone levels increase, negative feedback suppression is exerted on the androgen receptors in the hypothalamic neurons and pituitary gland, thereby inhibiting the release of GnRH, FSH and LH [5].

The Endocrine Society and American Urological Association (AUA) recommends treating symptomatic men with low testosterone documented on two morning fasting serum total testosterone concentrations. Both organizations recommend against the use of testosterone for treatment of hypogonadism in men who desire fertility in the next 6 to 12 months [3,4].

The exogenous administration of testosterone suppresses the release of gonadotropins (FSH and LH) to levels below that required for spermatogenesis. Spermatogenesis is largely dependent on the action of FSH on Sertoli cells coupled with high intra-testicular testosterone concentrations. Within the seminiferous tubules, only Sertoli cells possess receptors for both FSH and testosterone. Numerous signaling pathways are activated when FSH binds to FSH receptors on these cells. It acts synergistically with testosterone to increase fertility and the efficiency of spermatogenesis [6]. The inhibition of LH release by exogenous testosterone leads to the suppression of endogenous testosterone production by the Leydig cells. The decreased intra-testicular testosterone combined with the suppression of FSH leads to decreased germ cell survival and maturation (Fig. 1).

Image explaining the contraceptive effect of exogenous testosterone. In summary, it works by 2 mechanisms, decreasing intra-testicular testosterone, and inhibiting spermatogenesis. Most of the intra-testicular testosterone is made by the Leydig Cells in the testis. When exogenous testosterone is present, it inhibits gonadotropin-releasing hormone (GnRH) production which in turn inhibits luteinizing hormone (LH) production and decreases endogenous testosterone production by the Leydig cells, decreasing the intra-testicular testosterone concentration. Inhibiting GnRH production also inhibits follicle stimulating hormone (FSH) release, which impairs spermatogenesis in the Sertoli cells.

Intra-testicular testosterone is required in spermatogenesis for the formation of the blood-testis barrier (BTB). The BTB is a series of tight and adherens junctions between the Sertoli cells that separates postmeiotic germ cells in the adluminal compartment of the seminiferous tubules from the basal compartment containing the blood supply. During spermatogenesis, the BTB is disrupted and reformed as preleptotene spermatocytes pass through this barrier. In the absence of testosterone stimulation, spermatogenesis can only proceed as far as the prophase 1-leptotene stage of meiosis [7].

Testosterone is also required in maintaining connections between Sertoli cells and the haploid spermatid germ cells. Round spermatids are initially connected to Sertoli cells via desmosomes. As the spermatids mature and elongate, the desmosomes are replaced with stronger, specialized adherens junctions called ectoplasmic specializations, which are maintained until the release of mature sperm. Testosterone aids in this process and increases the efficiency of germ cell attachment to Sertoli cells. Testosterone is also essential for the release of mature spermatozoa from Sertoli cells. It has been shown that in the absence of testosterone stimulation, sperm are not released but are instead phagocytized by Sertoli cells [7].

Ultimately, the low intra-testicular testosterone results in decreased proliferation of spermatogonia, defects in spermiation of mature spermatozoa by Sertoli cells and accelerated apoptosis of spermatozoa [8,9,10,11]. Since 80% of testicular volume consists of germinal epithelium and seminiferous tubules, a reduction in these cells is usually manifested by testicular atrophy and this reflects the loss of both spermatogenesis and Leydig cell function [12,13].

Testosterone as a contraceptive can suppress spermatogenesis and lead to azoospermia in 65% of normospermic men within 4 months of use [14]. Cessation of exogenous testosterone will lead to the reversal of hormonally-induced azoospermia in 64% to 84% of men with a median time of about 110 days [13,14,15]. All men in these studies recovered to baseline levels after cessation of therapy; however, it took up to 2 years for some men to recover. These studies were performed in a controlled setting for a clinical trial, with a limited duration of testosterone use. In actual practice, recovery may not be as pronounced. Kohn et al [16] studied spermatogenesis recovery with human chorionic gonadotropin (hCG) and selective estrogen receptor modulators (SERM) in men with infertility associated with testosterone use. Thirty percent of the 66 men were not able to achieve a total motile sperm count of more than 5 million after 12 months in the study. They found that the failure of recovery is associated with older patients and longer TRT duration.

If fertility is affected because of TRT, couples may require the use of in vitro fertilization or intra-cytoplasmic sperm injection for future conception. These assistive reproductive technologies are expensive and are not always successful [17,18].

In summary, despite the androgenic effects of testosterone on sexual function, libido and mood; its effect on gonadotropins leads to the inhibition of sperm production [13]. This effect may diminish with the cessation of testosterone intake, but the extent of recovery is not clear for chronic users [16,19].

TESTOSTERONE AS A MALE CONTRACEPTIVE

Compared to the long list of contraceptive options available to women, men are limited to vasectomy and condoms. The former is challenging to reverse and the latter has failure rates as high as 18% because of noncompliance. Partners who correctly and consistently use condoms have failure rates of 2% [20,21]. As it is a user-dependent method, many couples seek easier to use options like female oral contraceptive pills or intrauterine devices [22]. However, there is a demand for alternatives. A survey of over 9,000 men from different populations in 2005 found that 29% to 71% of men are interested in using a form of hormonal male contraception [22,23].

In 1978, a newly available oral testosterone preparation known as testosterone undecanoate (TU) was investigated as a possible form for male contraception. The study found that regular testosterone use for 10 to 12 weeks causes suppression of sperm production, and even azoospermia, albeit inconsistently [24]. Ever since that study, testosterone has undergone extensive clinical trials as a hormonal method of male contraception and many have found testosterone to be efficacious, reversible and safe with minimal short-term side effects [23].

Unfortunately, the contraceptive effect of testosterone is not reliable. This has been proven in multiple studies, including two by the World Health Organization (WHO) Task Force on Methods for the Regulation of Male Fertility [14,15,25]. These two studies found an azoospermia rate of 64% to 75% in 6 months with testosterone enanthate [6,7]. A sperm concentration of 3 million/mL was used as a threshold for effective suppression of spermatogenesis in this study [14,15]. In a Chinese study of a monthly intramuscular TU injection, an azoospermia rate of 93% to 98% was achieved after 6 months with 1 million/mL as the criteria for effective suppression [25,26]. The different rates of azoospermia can be explained by the variable criteria and by ethnic differences in testosterone response [26,27]. These studies confirm the effectiveness of testosterone as a contraceptive, and provides evidence that men who desire fertility should not be prescribed TRT.

Even with this evidence, testosterone has not been approved by the USA Food and Drug Administration (FDA) for use as a contraceptive. In 2011, a phase II study for a combined TU/norethisterone enanthate formulation ended prematurely because of higher than anticipated adverse effects including mood changes (such as depression), increased libido, acne and weight gain [27,28].

More recent advancements were shown in the 2018 Endocrine Society meeting, with dimethandrolone undecanoate shown to effectively decrease sperm counts without adverse effects in a double-blind study in 2 academic sites. More extensive research on the safety of testosterone as a contraceptive needs to be done before testosterone can be used as a safe and reliable contraceptive [29].

FORMULATIONS OF TESTOSTERONE REPLACEMENT THERAPY

To date, many different testosterone formulations are available, each with their own side effect profiles. The selection of the preparation of testosterone requires a comprehensive discussion with the patient about the route of administration, cost and side effects of the individual formulations.

Oral methyltestosterone is the only form of oral testosterone approved for use in the USA. It is strongly associated with hepatotoxicity and the AUA recommends against using the formulation [2,3]. TU is approved for use in some countries but is not approved for use in the USA [4].

Topical options of TRT include gels and patches. They are relatively easy to administer and doses are able to be quickly altered when needed [30]. Their adverse effects include skin irritation seen with testosterone patches. Topical testosterone gels also run the risk of transference to others; but this can be avoided by using a clothing barrier [31,32].

Nasal testosterone gels (NTG) are a relatively newer form of TRT that is currently undergoing extensive research. It is seen to be advantageous over topical gels because of ease of use and the decreased risk of transference [33]. With regards to fertility, Conners et al [34] found that 4.5% NTG two or three times a day restored serum testosterone levels while only decreasing gonadotropin levels minimally, keeping serum FSH and LH values within the normal range. Its short half-life results in a return of serum testosterone to near baseline levels between doses. It is theorized that this decreases its effect on the pulsatile release of GnRH by the hypothalamus [35]. A phase IV clinical trial is currently evaluating its impact on semen analysis parameters, and it would be the first study to do so [36]. Based on what is found by future studies, NTGs may have the potential to be a suitable TRT option in men desiring fertility.

Intramuscular testosterone injections are another form of TRT. These include testosterone cypionate and enanthate, which are self-administered once every 1 to 2 weeks. Their starting dose is 100 mg weekly or 200 mg every two weeks before titrating in response to lab results on follow-up visits [3]. While the patients using these formulations will be able to avoid frequent trips to the clinic once the dose has been adjusted, it does require proper patient education to ensure compliance to the dose set by the healthcare provider. They also have a greater risk of side effects than other preparations [30,37]. One of these adverse effects is the 'up and down' phenomenon due to the variable release of the hormone into the bloodstream leading to peaks and troughs beyond the normal range of serum testosterone levels [5,30,38,39].

TU is another preparation of intramuscular testosterone that is longer acting than the other formulations. It needs to be administered with an initial dose of 750 mg, followed 4 weeks later by another 750 mg dose. This is then followed by an intramuscular injection once every 10 weeks. A disadvantage is that this preparation needs to be administered in the office as a slow injection over 2 minutes and patients need to be monitored for 30 to 45 minutes after administration due to the risk of developing pulmonary-oil micro embolism [4,40].

Beyond gels, patches and injections, another option for TRT are the subdermal implants. They are administered in a 10- to 15-minute procedure in the office every three to six months depending on follow-up laboratory results. This is a popular option among patients because they do not have to self-inject or apply gels repeatedly [30]. It is particularly helpful in patients who travel regularly, and the extended release decreases the 'up and down' feelings often experienced with the intramuscular injections. The disadvantages of subdermal implants include the need for regular office visits, pain and bruising at the site of insertion, as well as the minimal risk of infection and pellet extrusion [30].

In terms of the contraceptive effect of the different formulations of testosterone, most research has shown that transdermal and intramuscular testosterone seem to be the strongest contraceptive formulations. The WHO and Chinese studies used testosterone enanthate and TU, respectively. The topical formulations of testosterone have variable contraceptive effects. The testosterone patch was shown to be an ineffective contraceptive [41] while the gel had mixed results [42,43]. However, the sample size for most of these studies are not large enough to truly assess the extent to which fecundity is affected. More research needs to be done to evaluate the contraceptive effect of the various formulations of testosterone.

A list of the available testosterone formulations with its side effect profiles and effect on fertility can be found in Table 1 [3,14,15,25,28,41,42,43,44,45,46,47,48].

Table 1

List of testosterone formulations

USING TESTOSTERONE IN THE TREATMENT OF HYPOGONADISM IN MEN WHO DESIRE FERTILITY

Considering that there is abundant evidence demonstrating that TRT significantly decreases sperm production, it is important that clinicians consider the evidenced risks of male infertility before starting patients on TRT. It can be surprising to patients that testosterone can suppress fertility, in contrary to its stimulatory effects on libido and erectile function. The patient's desire for fertility must be discussed in depth and established prior to initiating testosterone. The discussion must also include future thoughts on fertility. This will allow the physician to manage the timing of hypogonadism treatment, essentially balancing the alleviation of hypogonadal symptoms with the patient's desires for fertility. This could also open discussion about cryopreservation of sperm as an option for the patient to preserve fertility further down the line.

Physicians should also educate men already on TRT. There has been an increase in TRT use among men aged 18 to 45 years and more than 20% of these men did not get a baseline testosterone level prior to initiation of TRT [49]. Some of these men may not know about its effects on fertility and may not have discussed it with their prescribing physician. The study also showed that less than 2% of men on TRT obtained a baseline semen analysis [49]. In addition to the routine serum total testosterone, LH, and hematocrit prior to starting TRT, every man of reproductive age should have a baseline semen analysis [3]. The baseline semen analysis will identify men with a decreased baseline sperm count, as a reference value for future semen analyses after TRT use.

If a patient currently desires fertility, TRT should be avoided or discontinued immediately. A semen analyses should be performed if the patient has discontinued TRT. Azoospermia or severe oligospermia may be seen in these patients, but most men should return to baseline semen analyses in 6 to 9 months after cessation of TRT [13,14,15]. A 2006 integrated analysis showed that 90% of patients were expected to return to baseline sperm concentration values 12 months after cessation of treatment and 100% after 24 months [50]. Furthermore, evidence in a 2015 study of 49 men showed that 3,000 units of hCG subcutaneously every other day is effective in supporting the recovery of spermatogenesis without significant adverse effects [11].

Regardless, the recovery of spermatogenesis is unclear for patients on chronic TRT. Physicians should take caution when treating hypogonadism in men who desire future fertility, but also acknowledge the reversible azoospermia seen in controlled studies [51]. Adjunctive hCG and clomiphene can be used with TRT to maintain testicular size and intra-testicular testosterone concentrations [52]. Referral to a reproductive urologist should be considered in a male with low testosterone interested in fertility.

ALTERNATIVES TO TESTOSTERONE THERAPY IN PATIENTS WHO WISH TO PRESERVE FERTILITY

Clomiphene and enclomiphene citrate provide an alternative treatment option for hypogonadal men that desire fertility as it does not affect sperm production. Clomiphene is a non-steroidal SERM. It selectively binds to estrogen receptors in the hypothalamus, antagonistically inhibiting negative feedback, increasing the levels of gonadotropins and stimulating the testicular production of testosterone in men [53].

Even though enclomiphene citrate is not currently FDA approved, it has been shown to increase serum testosterone by raising the serum LH and FSH levels without negatively affecting semen parameters [54]. Kaminetsky et al [55] conducted a proof-of-principle, randomized, open-label, fixed dose, controlled, two-center phase IIB study that compared 25 mg of enclomiphene citrate daily to topical testosterone in hypogonadal men. The results showed higher testosterone levels and sperm counts in men receiving enclomiphene citrate. This corroborates with other studies which show improved semen parameters with the use of clomiphene citrate, with some studies describing it as a treatment for male infertility [56,57].

hCG has also been used (often with clomiphene citrate, tamoxifen or anastrozole) because it stimulates the production of endogenous testosterone without compromising spermatogenesis. Although the exact mechanism of action and production site in males are not fully understood, it is known that hCG mimics the effects of LH and stimulates the Leydig cells in the testicles to produce endogenous testosterone [3,58,59,60]. Additionally, studies have shown that low-dose hCG can be used with TRT to maintain high levels of intra-testicular testosterone while men are being treated for hypogonadism [52,61]. While hCG is effective in increasing testosterone, various studies have shown that it is also efficacious in inducing spermatogenesis [62,63]. It is even effective in helping with the recovery of spermatogenesis in men who were on TRT [11]. Clinicians generally agree on using 2,000 IU of hCG administered subcutaneously 3 times per week as defined by the 2002 American Association of Clinical Endocrinologists guidelines [64].

The ideal treatment for hypogonadism should provide physiological testosterone levels, exhibit appropriate circadian rhythms and be modulated by the HPG axis. No formulation of testosterone has been able to achieve this. However, there has been recent ongoing research on autograft Leydig stem cells. This may prove to be an effective treatment for hypogonadism in the future as it has the potential to fulfill all the criteria of an ideal TRT [65]. Makala et al [66] found that serum testosterone levels and Leydig cell populations were restored over time in mice who underwent ectopic autografting of testicular tissue. These results indicate that Leydig cells are able to regenerate de novo in the autografted adult testes, subsequently restoring serum testosterone level. In 2017, Zang et al [65] also demonstrated how direct transplantation of stem Leydig cells are capable of self-renewal, extensive proliferation and differentiation into mature Leydig cells. These Leydig cells can then be regulated by the HPG axis and restore the neuroendocrine regulation of testicular function and its diurnal testosterone production system. Having said that, these strategies still face major hurdles with regards to its clinical translatability and the ethics of cell transplantation.

CONCLUSIONS

Testosterone therapy is a contraceptive, albeit a poor one. Men of reproductive age with low testosterone should be counseled on the adverse effects of TRT on fertility. Obtaining a semen analysis and possible cryopreservation of sperm should be offered if TRT is prescribed to men interested in preserving fertility. Options such as clomiphene citrate and hCG along with a referral to a reproductive urologist should be considered to naturally increase testosterone levels in those men with low testosterone who want to avoid TRT.

ACKNOWLEDGEMENTS

The authors would like to thank the physicians and patients of Jackson Memorial Hospital, University of Miami Hospital, and the Miami VA for inspiring the creation of this review for clinician use.

Footnotes

Disclosure: The authors have no potential conflicts of interest to disclose.

Contributed by

Author Contribution:

• Conceptualization: Ramasamy R.

• Data curation: all authors.

• Formal analysis: all authors.

• Funding acquisition: none.

• Investigation: all authors.

• Methodology: all authors.

• Project administration: Ramasamy R.

• Resources: none.

• Software: none.

• Supervision: Ramasamy R.

• Validation: all authors.

• Visualization: all authors.

• Writing (original draft): all authors.

• Writing (review & editing): all authors.

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Will Taking Testosterone Lower My Sperm Count

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305868/

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What Will Happen If I Start Taking Testosterone

What Will Happen If I Start Taking Testosterone

Should the Modern Man Be Taking Testosterone?

Testosterone deficiency is exceedingly less common than marketing campaigns and "you only think you feel fine" culture would have us believe.

By now you've likely seen the commercials. Fit-looking middle-age men telling you how they put on weight, had less energy, and were no longer the sexual tigers they were in their twenties—until, that is, they started rubbing testosterone gel on their shoulder, upper arm, or abdomen.

Now they feel more like the men they used to be.

The commercials don't mention a 2009 study in the New England Journal of Medicine wherein a group of men on testosterone replacement therapy had more than four times the number of cardiovascular problems—so many that the study had to be halted.

They also don't make clear how risky exposure to testosterone gel is for others—female partners, children, even pets. The gel is actually notorious for transferring to others. It can cause excess hair to grow on women's faces and arms, deepen their voices, interrupt menstruation, and make them anxious and irritable. In children, exposure to testosterone gels and creams can cause premature puberty and aggression. And in pets, it can cause aggressive behavior and enlargement of the genitalia.

Commercials do mention other potential side-effects for the male user, calling them "rare," including swollen and painful breasts, blood clots in the legs, increased risk for prostate cancer, problems breathing during sleep (sleep apnea), change in the size and shape of the testicles, and a low sperm count. But you're not supposed to focus on the details. Instead, just think of the energy you'll have. The great sex you'll have. And the muscles. It will be a veritable second adolescence as your aging body bursts into new bloom.

Don't get me wrong. The medical experts interviewed for this article emphasized that low testosterone—also known as hypogonadism or hypotestosteronemia—is real for a slim percentage of men. They hastened to add, however, that a normal "T" level for one man may be low for another.

According to British Medical Journal (BMJ), the European Male Ageing Study has provided the best estimate of the prevalence of low T—defined as a combination of sexual symptoms and measured testosterone level—finding that only 0.1 percent of men in their forties, 0.6 percent in their fifties, 3.2 percent in their sixties, and 5.1 percent of men in their seventies would meet the criteria for the diagnosis.

Unlike menopause in women—when estrogen levels plummet and stop almost completely—testosterone levels in men normally fall by only 1 to 2 percent per year after age 40.

"Low T" is anything but inevitable. BMJ's Drug and Therapeutics Bulletin says that around 80 percent of 60-year-old men, and half of those in their eighties, have testosterone levels within the normal range for younger men. It concluded, "The evidence that an age-related reduction in testosterone levels causes specific symptoms is weak." The Food and Drug Administration (FDA) meanwhile has not approved testosterone use to improve strength, athletic performance, physical appearance, or prevent aging. And a 2004 report from the Institute of Medicine ("Testosterone and Aging: Clinical Research Directions") called TRT for age-related testosterone decline a "scientifically unproven method."

"A proportion of older men will predictably have testosterone concentrations below the normal range of healthy young men," wrote BMJ deputy editor Tony Delamothe, in a 2012 commentary. He added, "It seems a bit harsh to turn an age-related phenomenon into a disease, but that's what's happened."

In the age-old tradition of snake oil peddlers and traveling medicine shows, TRT is but the latest elixir from the fountain of youth. Offering a heady brew of hope and hype distilled at the drawing boards of advertising agencies, tubes of testosterone are the latest wares for the unwary.

***

So what is this Big T, anyway? Derived from cholesterol, testosterone is a steroid hormone—called an androgen—that causes the development and maintenance of masculine characteristics. It's mainly secreted by the testicles in males, although the adrenal cortex and ovaries in females also secrete testosterone—though only about one-tenth the amount as in healthy males.

Interest in testosterone began when farmers of old first noticed that castrated animals were more docile than their intact peers. Ditto for castrated humans. For human males with intact gonads, testosterone increases during puberty. It deepens the voice, increases muscle growth, promotes facial and body hair, and spurs the sex drive. Testosterone also is associated with personality traits related to power and dominance.

Testosterone levels fluctuate throughout the day, and are usually highest in the morning. They peak in the late teens to early twenties, after which they decline slowly, but steadily, as men age. Although there is no standard definition of "low" testosterone, a healthy range spans between 250 to 1,100 nanograms per deciliter of blood.

Questions inevitably arise: If even scientists don't agree on what, exactly, "low T" means, how can anyone diagnose it? At what point is it problematic? And, most importantly, how can you know whether you are a candidate for TRT?

"I am very cautious about committing someone for life to medication," said Dr. Kathleen L. Wyne, who directs research on diabetes and metabolism at Houston's Methodist Hospital Research Institute and serves on the Sex Hormone and Reproductive Endocrinology Scientific Committee for the American Association of Clinical Endocrinologists. "That does frustrate patients because they have heard about [Low T] from TV and friends."

Although her male patients may or may not get the low testosterone diagnosis they believe Dr. Wyne should give them, they will get a comprehensive examination. Besides their testosterone level, she will look at their triglycerides, glucose (blood sugar) tolerance, liver enzymes, and other counts as well as the condition of their testicles. "I need to know if they're normal going into it," she explained.

Dr. Wyne told me that although she has seen an increase in male patients asking about low testosterone, she hasn't seen an actual increase in the condition itself. "I do see an increase in guys who are fatter," she said. "The question is whether, if you lose 15 or 20 pounds, your testosterone would revert [to normal]. We know that even 15 pounds makes a huge difference to their level. Most of these guys actually have 50 pounds to lose."

In Seattle, Dr. Bradley D. Anawalt, an endocrinologist and professor of medicine at the University of Washington, said it's challenging for physicians to tease out the actual causes of a man's low energy, drop in sexual interest, and other potential symptoms of low testosterone that may as likely be caused by something else.

"The hard part," said Dr. Anawalt, "is the man who is 50 pounds overweight and sedentary, who sees a TV ad and goes to see his doctor. Let's say he has a thoughtful doctor who does the right test, at the right time of day (morning), and the test comes back low. Many of these guys will have low or slightly low testosterone. We have no evidence for whether or not it's a benefit to give these guys testosterone." He added that concern about their testosterone level could be a good thing if it spurs men to lose weight and exercise. "A low testosterone level can be a marker of poor health," he said.

Dr. Anawalt called the diagnosis and treatment of low testosterone a careful balancing act. "You don't want to leave the impression that no one is at risk for low testosterone," he said. He explained that physicians need to be aware that men coming in with low libido, sexual function, osteoporosis, or new breast sensitivity might well have low testosterone. Besides measuring testosterone— usually two or even three times—confirmatory tests will also measure other hormones that regulate testosterone and sperm production in the testicle. "If they don't have that evidence," said Dr. Anawalt, "we will tell a man we don't think you're suffering from the effects of low testosterone."

Sometimes, low testosterone can actually be a good thing. In fact there are hundreds of thousands of men in North America at any given time whose T level is intentionally lowered using drugs derived from testosterone or estrogen. These are men being treated for prostate cancer.

Richard J. Wassersug, PhD, an adjunct professor of urology at the University of British Columbia, described his personal experience with androgen deprivation therapy (ADT). "If you are on ADT," he said, "and you see those Low T ads, what are you supposed to make of it? This produces a cognitive dissonance." He called the ads "hurtful" for suggesting that low testosterone makes a man less of a man.

Dr. Wassersug, whose background is in evolutionary biology, also noted that lower testosterone in older men may be adaptive, a positive benefit, as our bodies age and become increasingly frail. "The argument can be made," he said, "that it's not beneficial to have the mindset of a 19-year-old when you are 49-years-old, because if you are aggressive enough to get into a conflict with an actual 19-year-old, you are going to get killed."

***

When Solvay Pharmaceuticals, maker of market-dominating Androgel, launched its "Low T" campaign, in 2008, it claimed that 13 million American men over age 45 suffered from low testosterone, 90 percent of them undiagnosed. Its website, IsItLowT.com, showed dumpy, depressed men and their unhappy spouses remembering how it "used to be." Why settle for dumpiness and depression, the website and related TV ads suggested, when a little dab'll do you?

In its first year alone, 1.4 million prescriptions for AndroGel were written in the U.S., most of them for 50 to 59-year-old men. Today, numerous websites peddle the drug without requiring a prescription.

Interestingly, the Belgian company Solvay, acquired for €4.5 billion in 2010 by American pharmaceutical giant Abbott, didn't put its own or its product's name on the website. As AdWeek pointed out when the campaign launched, "One of the advantages of taking the unbranded route for Androgel is that the company does not have to warn consumers quite so prominently about Androgel's side effects."

Dr. Adriane Fugh-Berman, associate professor of pharmacology and director of the industry watchdog group PharmedOut.org at Georgetown University School of Medicine, calls this kind of direct-to-consumer pharmaceutical advertising "evil." She likened the efforts to sell TRT to earlier campaigns to push hormone replacement therapy for post-menopausal women. "They stole the playbook," she said. "This hormone is being thrown around like sugar water."

"By expanding the boundaries of this disease to common symptoms in aging males, such as fatigue and reduced libido, drug companies seek to increase their markets and boost their sales," wrote Barbara Mintzes, an assistant professor at the University of British Columbia School of Public Health, and Agnes Vitry, a senior research fellow at the University of South Australia, in a 2012 article in the Medical Journal of Australia .

In Australia, where it is illegal for drug makers to advertise directly to consumers—as it is everywhere except the United States and New Zealand— Dr. Vitry told me via e-mail that the country's FDA-like regulatory body, Medicines Australia, fined Bayer a minuscule, but symbolic, 10,000 Australian dollars for breaching MA's code of conduct in its TRT disease-awareness campaign. Although Bayer implied that low testosterone was the most prevalent cause of the symptoms described, and that there was a high incidence of low T, Vitry said Medicines Australia didn't nail Bayer for illegal direct-to-consumer advertising because its campaign "did not encourage patients to seek a prescription for a specific testosterone product."

These "disease-awareness" campaigns—ostensibly a public service intended to educate those potentially at risk about a condition they may not even have heard of but "could" have—are subtle, even insidious. They may not mention a specific product, but a bit of sleuthing reveals that their sponsors are usually pharmaceutical companies that "just happen" to manufacture products used to treat the real (or at least alleged) condition.

Dr. Fugh-Berman said these campaigns encourage men to "ask your doctor" whether their weight gain, falling asleep after dinner, reduced energy, and diminished sex drive are due to "Low T." At the same time, the companies are working other angles to influence doctors' prescribing practices through industry-sponsored continuing medical education (CME) courses and sponsored medical journal articles. They have even created a respectable-sounding journal called The Aging Male. Fugh-Berman said all these channels "are being used to persuade doctors they should be treating this."

After bombarding consumers with advertising, and massaging physicians with free meals and medical "information," the stage is set to seal the deal. "The fat guy has been seeing the ads on TV," said Fugh-Berman. "The doc has just come from a medical meeting where they were talking about how using testosterone can fight depression, etc., and they are being primed in a different way."

In the U.S., where millions watch the Super Bowl simply to see the clever and costly commercials, and where pharmaceuticals with potentially deadly side effects are pushed on the public at every turn, it's probably not surprising that ads for "Low T" are now splayed across billboards in Florida, with its huge number of older residents, or that a chain of "Low T Centers" has sprung up in Texas and around the heartland.

"Bring back the younger inner you," says the Low T Center. According to its website, its president, Mr. (notably not "Dr.") Mike Sisk, "created these centers out of a need." They promise their testosterone injections "do not just help boost a low sex drive but can also boost energy, decrease body fat, irritability, and depression." They go so far as to claim that "research finds testosterone replacement can solve long-term health issues like Alzheimer's and heart disease."

Best of all? It's easy. "Low T Center is set up so men can walk in, take a simple blood test, and know within 30 minutes whether or not they are a candidate for testosterone replacement therapy, or TRT. Men who qualify get their first injection on the spot, and will continue to come in three times per month to receive a quick testosterone injection."

Step right up! Right this way. Whether you take your "T" by injection, gel, patch, or subcutaneous pellet, the promise of eternal youth can be yours for the taking.

"I testified against one of these centers in Texas," said Dr. Fugh-Berman. "[The owner] offered me a free workup. I said thank you for your offer, what is it you charge for your first visit? Two thousand dollars? I said I feel fine. He said 'You just think you feel fine.'"

***

According to the Endocrine Society, the world's oldest, largest, and most active organization devoted to research on hormones and the clinical practice of endocrinology, "androgen deficiency"—another name for low testosterone— should be diagnosed "only in men with consistent symptoms and signs and unequivocally low serum testosterone levels."

The group's 2010 clinical practice guidelines make it clear that "the threshold testosterone level below which symptoms of androgen deficiency and adverse health outcomes occur and testosterone administration improves outcomes in the general population is not known." They also clearly advise against screening men in the general population to avoid "labeling and medicalization of otherwise healthy men for whom testing, treatment, and monitoring would represent a burden with unclear benefit."

Dr. Ronald Swerdloff, chief of the endocrinology division at the Harbor-UCLA Medical Center and a professor of medicine at UCLA's David Geffen School of Medicine, served on the panel of experts who developed the Endocrine Society's guidelines. He is also the principal investigator for one of the 12 sites of The Testosterone Trial in Older Men, a nationwide study funded mainly by the National Institute on Aging. The study of 800 men over age 65 with low testosterone is looking at whether men using AndroGel for one year, compared to placebo, will show improvements in walking speed, sexual activity, vitality, memory, and anemia. The study will be completed in June 2015.

"The hope," explained Dr. Swerdloff in a telephone interview, "is this will provide some clarity as to whether testosterone replacement therapy will benefit men in this older age group who clearly have abnormal testosterone and have some symptoms." He added, "We don't know whether it will be beneficial at all the endpoints we are studying, or be beneficial to some and not others. We don't know if the benefits occur at different blood levels that are attained in the individuals."

He said it's also important to point out there may be different thresholds for different people. "One man might get low libido at 325 milligrams per deciliter, while another might not get low libido until 450," he said. As for doctors who say that every man of a certain age will benefit from TRT, Dr. Swerdloff said, "It should not be treatment based on age. It should be treatment based on the best available laboratory and clinical data. Those patients who don't meet the criteria for treatment should not be treated unless there is some logical reason why they are outliers from the usual type of pattern."

Even before the study yields its findings, Dr. Swerdloff said a few important points should be emphasized. "I want to make it clear that this is not a made-up disease," he said. "It is well known in younger men that if you have a failure to produce normal testosterone, there are certain signs and symptoms that create a kind of syndrome. Treatment for low testosterone has been documented to be beneficial."

Barbara Mintzes, at the University of British Columbia, said in a Skype interview, "Androgel was approved for a real condition—men who have a number of clinical or acquired conditions that affect testosterone, either through the testes or pituitary gland. So testosterone replacement therapy makes sense, and producing it in a gel makes sense. Where there is an actual need for the product, there's nothing wrong with that." But, she added, "When this gets marketed for what is essentially healthy aging, the antennas go up."

Dr. Wyne, in Houston, said, "When I hear a catchy little phrase, or someone is trying to get us to use a drug that is not based on clinical data, the cynical part of me asks where did it come from." She added, "There is a very important role for testosterone replacement therapy. It's wonderful that we have all these options, but we need to be using them appropriately, in a safe and efficacious manner."

Related Story

There's the rub, so to speak. Recalling the cautionary lessons learned about sex steroid hormone therapy in postmenopausal women from theWomen's Health Initiative, Dr. Brad Anawalt wrote in the Journal of Clinical Endocrinology and Metabolism, "We are threatened with a reprise of promiscuous prescription of sex steroid hormone therapy in aging men, obese men, diabetic men, and other groups of men with a high prevalence of low serum androgen levels. We are threatened with a mad 'T' party."

In our interview, Dr. Anawalt said, "It's a sexy term to say you have 'Low T.' So it's eye-catching and it's relatively easy to document that someone has a low testosterone level." And some men do. But, he said, "It's being packaged and marketed not just by the makers of testosterone products, but by doctors and marketers as a panacea."

What Will Happen If I Start Taking Testosterone

Source: https://www.theatlantic.com/health/archive/2013/04/should-the-modern-man-be-taking-testosterone/274663/

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5 Bedroom Floor Plans 2 Story

5 Bedroom Floor Plans 2 Story

Tips to Help You Design a Home Floor Plan

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Designing your own home can be an exciting project, and you might be full of enthusiasm to get started. You likely already have some idea as to the kind of home you have in mind. Your mind is buzzing with ideas, but you're not quite sure how to get started. Continue reading to get some tips on how you can best bring your vision to reality.

Start Simple

There's no need to get fancy software to begin making decisions about your custom home design. All you really need is a pencil, a piece of paper and a dream. Sketch out your ideas, and brainstorm with anyone who enthusiastically supports your vision. Get your ideas out of your head and onto paper and they will begin to take shape. Make lists of the features you want your home to have. Make a list for each room in your home, and decide on the features you absolutely must have versus the ones you'd like to have. Even rough sketches can help your home designers get an understanding of what you want.

Plan for the Future

If you're planning on living in your home for a long time it's a good idea to keep future needs in mind. Do you have children or are planning on having them? Are there aging family members that may move in with you in the future? Are you anticipating future mobility issues on your part? Do you expect your college age kids to move back home? Will you have visiting relatives or friends to accommodate? If you plan on working from home you will need a quiet space where no one will disturb you. All these things need to be taken into consideration when you start planning your new home. What may seem like a good idea right now may not work for you 10 years down the road.

Make the Most of Your Land

Often, those interested in designing a custom home already own the property where their home will be built. If you already know where you'll build your home, consider the topography, as well as the size and best features of your land. If your land overlooks attractive nature scenes, such as a lake or mountains, it makes sense to place your home so you can see them from your favorite rooms.

If you have a stream or brook running through your property, you may choose to place bedrooms nearest them so you can be soothed by their tranquil sound. In addition to this, you will want to take note if your land is sloped or flat. Custom home for sloped land will look very different to the one that's meant for a flat lot.

Think About Light

Light has a healing and soothing effect on humans, and in areas that experience very little light in the winter there are many cases of Seasonal Affective Disorder. This disorder can bring feelings of depression and lethargy, among other symptoms. If you have ever suffered from this in the past, or are living in a place with long, dark winters, it's a good idea to add skylights to your design so that natural light is maximized. Skylights are a great idea anyways because they reduce the need for artificial light in your home. They also provide as much as 30 percent more light than vertical windows. Another thing to consider is which direction you want the rooms in your house facing. Would you want light from the west shining into your living room or bedroom? Does breakfasting with the morning sun shining into your dining area appeal to you?

Prioritize Features

Once your rough draft is finished, it's time to decide what's important versus what you merely fancy having. Things that are functional for your lifestyle on a daily basis, should take precedence over anything that's merely a whimsy; unless you have the budget of course. That's not to say you can't have features that may not be practical but that bring joy to your life. If you really want a ballroom you can certainly have that, as long as it doesn't come at the expense of having enough bedrooms for family members. But ultimately only you can decide what's really important to you, and what will make you happy. After all this is your dream home you're designing.

Go With the Flow

Consider how your final design will allow you and your family to function in each area of your home. Decide the best place where various rooms should be located to maximize what they're intended for. For example, to reduce noise in bedrooms, it's best to place them away from boisterous communal areas of the home. If you enjoy being with your family an open floor plan may suit you. This way you get to hang out with your family, instead of each member being hidden away in a room somewhere. This kind of design will also allow for more light in your home.

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5 Bedroom Floor Plans 2 Story

Source: https://www.questionsanswered.net/article/tips-to-help-you-design-a-home-floor-plan?utm_content=params%3Ao%3D740012%26ad%3DdirN%26qo%3DserpIndex

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Large Bedroom Windows

Large Bedroom Windows

The Best Replacement Windows for Your Home

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Windows are both a practical item and a beautiful addition to any home. You can let light in and bring a little bit of the outdoors into your house. Like any feature of your home, windows can and will wear out, and you'll need to replace them sooner or later.

How do you find the right windows? There are so many different kinds that shopping can be overwhelming. Here are the best replacement windows as rated and reviewed by consumers like you.

Best Overall: American Craftsman 70 Series Pro Double Hung White Vinyl Window With Buck Frame

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Best Value: TAFCO Single Hung Vinyl Window

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If you're seeking a quality window at a price you'll love, check out the TAFCO Single Hung Vinyl Window. You can bring in light and breezes with this classic window, and the screen keeps bugs out. It's everything you want in a window at a value price. Approximately 60 percent of reviewers give this window 5 stars for quality and value.

Best Double-hung Window With Grilles: American Craftsman 70 Series Pro Double Hung White Vinyl Window with Buck Frame and Grilles

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Best Single-hung Vinyl Window: American Craftsman 50 Series Single Hung White Vinyl Window With Nailing Flange

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Best Single-hung Aluminum Window: TAFCO Mobile Home Single Hung Aluminum Window

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If you live in a mobile or modular home, you should consider an aluminum window like the TAFCO Mobile Home Single Hung Aluminum Window. This window comes in several standard sizes, and its easy operation makes it a good basic window. Reviewers love the fit, function, and easy installation of this single-hung aluminum window.

Best Skylight: Velux Curb Mount Glass Skylights

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A skylight can let beautiful light into your home, and the Velux Curb Mount Glass Skylights gives you options. You can choose from a fixed skylight, a manual window, or solar and electric options for room darkening. It's safe and guards against leaks as well. More than 70 percent of buyers give this window 5 stars for the value and look of this flat replacement skylight.

Best Slider Window: Park Ridge VBSI3214PR Vinyl Basement Slider Window

Photo Courtesy: Amazon

A slider window is practical for a basement room or any room on the back of your home, and the Park Ridge VBSI3214PR Vinyl Basement Slider Window is your best option. The slide works effortlessly, and the window stays insulated when you close it. You can remove the screen if you choose. Reviewers rave about the value of these windows, especially compared to a professional installation.

Best Awning Window: TAFCO 32 in. x 16 in. Awning Vinyl Window With Screen

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You can add a classic touch to your home with an awning window above your front door. The TAFCO 32 in. x 16 in. Awning Vinyl Window with Screen gives you that old-school charm with modern construction. It's tough and secure, and the screen keeps bugs out. Two-thirds of reviewers give this window five stars for the look it adds to any project.

Best Hopper Window: TAFCO 31.75 in. x 21.75 in. Hopper Vinyl Window

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A hopper window is a great option for letting light and ventilation into a basement. The TAFCO 31.75 in. x 21.75 in. Hopper Vinyl Window is ideal for your finished or unfinished basement. It's built for insulation and easy cleaning. Nearly 65 percent of buyers give it 5 stars for how well they fit and how easily they install.

Best Picture Window: TAFCO Utility Fixed Picture Vinyl Window with Grid

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Picture windows don't open, so if you're looking for a window for the view, you'll love the TAFCO Utility Fixed Picture Vinyl Window with Grid. These windows have individual panes of glass in each part of the grid, and they're built to last. The frame is vinyl, and it resists ultraviolet damage. Reviewers love how easy these windows are to install.

Advertiser Disclosure: When you purchase through links on our site, we may earn an affiliate commission.

More From ConsumerSearch.com

Large Bedroom Windows

Source: https://www.consumersearch.com/home-garden/best-replacement-windows?utm_content=params%3Ao%3D740007%26ad%3DdirN%26qo%3DserpIndex

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Paris Themed Bedroom For Adults

Paris Themed Bedroom For Adults

Classic, effortless and chic are just a few ways to describe the style of a Parisian and the way they decorate their homes is no different. If you are following us, you may have seen that we've shared ideas on decorating living rooms and bathrooms like a Parisianne, and today's roundup is dedicated to the most sacred place in each home – the bedroom.

Rock Lights

Parisian homes are all about embracing light shades: keep walls and curtains serene white and add small touches of muted colors, though it's no necessary – you can keep it all neutral. You may go for a dark herringbone clad wooden floor that will contrast the walls and look cooler.

a beautiful Parisian bedroom with a faux fireplace, art deco lamps, a bed with muted pillows

a chic neutral Parisian bedroom with a faux fireplace, a statement mirror, a neutral chair and a large bed

a chic Parisian bedroom with a gold bed, a crystal chandelier, a refined chair and blush and black curtains

a chic Parisian bedroom with printed curtains, a crystal chandelier, a retro metal bed, a chic mustard loveseat and a marble clad fireplace

a chic Parisian space with a statement mirror headboard, a large bed, mirror panels and an antique lamp

Mix Styles

Mixing modern and traditional styles in an understated way is something Parisians are fantastic at. Although we may not all have high ceilings, period fireplaces and wooden herringbone flooring like a lot of the French – mixing your classics with more urban pieces like colorful plastic chairs, fun rugs, distressed wood, unusual lamps or art prints is an easy way to create the eclectic look and inject a bit of playfulness.

a chic sleeping space with grey textiles, a leather chair, a small desk in the corner, a non-working fireplace and a comfy bed

a creative Parisian bedroom with a catchy bed with acrylic framing, a green bench, catchy artworks and blush walls

a dreamy Parisian bedroom done in neutrals and blush, with an arrangement of mirrors, refined vintage furniture with gold inlays

a moody refined bedroom with a statement chandelier, artworks, stucoo, a dark upholstered headboard and sophisticated furniture

a neutral Parisian bedroom with a blue non-workign fireplace, a statement lamp, a chic mirror and an antique wooden chair

Add Antiques

The French are known for their flea markets. It's no wonder then, that Parisians have mastered a rustic look full of character whilst still achieving elegance. Try buying one statement antique like a bureau, chandelier or even iron bed frame as a centerpiece to the room. Compliment with soft, feminine furnishings like ruched bedding and silk curtains.

a neutral Parisian bedroom with a refined bed, a crystal chandelier, a mirror and flowy draperies

a neutral Parisian bedroom with antique wooden furniture, a crystal chandelier and large windows to fill the space with light

a Paris-inspired chic bedroom with a shutter screen as a headboard, a herringbone floor, mustard curtains and a comfy chair

a romantic Parisian bedroom with antique wooden furniture, a metal bed, powder blue curtains, a crystal chandelier is filled with light

a small attic Parisian bedroom with artworks, a comfy bed, lamps and stucco for decorating the walls

Accessorize

Parisians know how to embellish and will almost always have a vase full of flowers, scattered literature or a gorgeous rug somewhere in their home. Perfect for that laid nonchalant look we all envy. Have an exposed clothing rail or a stacked pile of books on the floor. Even by adding seating and faux fur to your bedroom, you can blur the line between rooms for that apartment vibe. Find more amazing ideas to make your bedroom look like it's in Paris below!

a very elegant Parisian bedroom with a printed rug, a chic upholstered bed, a crystal chandelier and mirror nightstands

a white Parisian bedroom with a statement mirror over the fireplace, an upholstered bed, a chic tufted sofa and much natural light

a white Parisian bedroom with airy curtains, an upholstered bed, an artwork and a chic tufted chair in the corner

an antique-inspired Parisian bedroom in neutrals and soft touches of blue, with sophisticated furniture and chic draperies

an elegant Parisian bedroom with a herringbone floor, a statement mirror, a chic crystal chandelier and a refined chair

an elegant Parisian psace done with gold, beige, blues and a chic chandelier, an upholstered bench and refined furniture

Paris Themed Bedroom For Adults

Source: https://www.digsdigs.com/parisian-bedroom-decor-ideas/

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