To all the hot men at american family

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RYAN C. Related editorial : Treating Aging with Testosterone.

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See the CME Quiz. Testosterone therapy is increasingly common in the United States, and many of these prescriptions are written by primary care physicians. There is conflicting evidence on the benefit of male testosterone therapy for age-related declines in testosterone. Physicians should not measure testosterone levels unless a patient has s and symptoms of hypogonadism, such as loss of body hair, sexual dysfunction, hot flashes, or gynecomastia.

Depressed mood, To all the hot men at american family, decreased strength, and a decreased sense of vitality are less specific to male hypogonadism. Testosterone therapy should be initiated only after two morning total serum testosterone measurements show decreased levels, and all patients should be counseled on the potential risks and benefits before starting therapy. Potential benefits of therapy include increased libido, improved sexual function, improved mood and well-being, and increased muscle mass and bone density; however, there is little or mixed evidence confirming clinically ificant benefits.

The U. Food and Drug Administration warns that testosterone therapy may increase the risk of cardiovascular complications. Other possible risks include rising prostate-specific antigen levels, worsening lower urinary tract symptoms, polycythemia, and increased risk of venous thromboembolism. Patients receiving testosterone therapy should be monitored to ensure testosterone levels rise appropriately, clinical improvement occurs, and no complications develop. Testosterone therapy may also be used to treat hypoactive sexual desire disorder in postmenopausal women and to produce physical male sex characteristics in female-to-male transgender patients.

The use of testosterone therapy is increasingly common in the United States, with an estimated 2. Male hypogonadism should be diagnosed only if there are s or symptoms of hypogonadism and total serum testosterone levels are low on at least two occasions. Food and Drug Administration clarified in that prescribing testosterone for low testosterone levels due to aging constitutes off-label use.

Enlarge Print. Testosterone therapy should be considered for men with low testosterone levels and clinical symptoms of hypogonadism, particularly sexual dysfunction. Before starting treatment, male hypogonadism should be documented with low morning testosterone levels on two occasions. Men considering testosterone therapy should be counseled about the uncertainty of the long-term safety of testosterone, including possible cardiovascular harms, and patients and physicians should engage in shared decision making, weighing the risks and benefits of therapy.

Men receiving testosterone therapy should be monitored regularly for adverse effects and treatment effectiveness, including testosterone measurements, complete blood count to measure hematocrit, and prostate-specific antigen testing. Testosterone therapy may be considered for treatment of postmenopausal women with hypoactive sexual desire disorder.

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Do not prescribe testosterone or testosterone products to men contemplating or attempting to initiate pregnancy. Do not prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

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Do not prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency. Do not prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency. Testosterone is produced by Leydig cells in the testes, in response to luteinizing hormone produced by the pituitary gland. Decreased production of testosterone by testes in men is categorized as hypogonadism, which is classified as primary, secondary, or mixed. Primary hypogonadism is the failure of the testes to produce sufficient testosterone, whereas secondary hypogonadism is caused by decreased production of luteinizing hormone.

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Table 1 lists the most common causes of hypogonadism. Chronic opioid use, hyperprolactinemia, pituitary tumors, sellar radiation, sleep deprivation, surgery, trauma. Aging, cancer, chronic glucocorticoid use, chronic kidney disease, chronic obstructive pulmonary disease, cirrhosis, diabetes mellitus, hemochromatosis, human immunodeficiency virus infection, obesity. Information from references 4 and 5.

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Testosterone levels begin to decline around 40 years of age. According to guidelines from the Endocrine Society, male hypogonadism should be diagnosed only if there are s or symptoms of hypogonadism Table 2 389 and total serum testosterone levels are low on at least two occasions.

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Information from references 38and 9. Because of circadian variations in testosterone levels, serum testosterone measurement should occur in the morning, or within two hours of awakening in shift workers Figure 1 9. Although there is no universal laboratory definition of hypogonadism, in most laboratory reference ranges, the lower limit of normal is between and ng per dL 8. In men with borderline total testosterone levels, measurement of free testosterone and sex hormone—binding globulin levels should be considered, especially in the presence of conditions that affect sex hormone—binding globulin levels most commonly, aging, obesity, and diabetes.

If low testosterone is confirmed, luteinizing hormone and follicle-stimulating To all the hot men at american family levels should be measured to categorize the deficiency as primary or secondary. Information from reference 9. A common indication for testosterone therapy is treatment of decreased sexual desire or erectile dysfunction.

A systematic review found 23 randomized trials of testosterone therapy's effects on libido; 13 trials showed some benefit, eight showed no benefit, and two had mixed. Although evidence regarding erectile dysfunction is mixed, young men with hypogonadism and erectile dysfunction appear to benefit from testosterone therapy. There is some evidence supporting the use of testosterone therapy as second-line therapy in men with low testosterone when phosphodiesterase-5 inhibitors are ineffective.

As part of the Choosing Wisely campaign, the American Urological Association says physicians should not prescribe testosterone therapy for men with erectile dysfunction and normal testosterone levels. Low testosterone levels less than ng per dL [7. Testosterone therapy consistently increases lean mass and decreases fat mass, 25 — 27 but the effect sizes are small and studies have generally failed to demonstrate improvement in strength or physical function. The few studies of testosterone therapy for depressed mood had mixed. In a advisory, the U. Food and Drug Administration FDA warned that testosterone use is possibly associated with increased cardiovascular risk and advised physicians to discuss this risk with patients before initiating testosterone therapy.

Although the findings of the TOM trial are concerning, this study enrolled a high-risk population, and its findings may not be generalizable to most men being considered for testosterone therapy. Proponents of testosterone therapy point to a large of observational studies consistently finding higher cardiovascular morbidity and mortality in men with low baseline testosterone levels and suggest that treating low testosterone should lead to decreased risk, 49 although it is unclear whether low testosterone was a cause of the increased cardiovascular risk or merely a marker of poor overall health.

No randomized controlled trial has demonstrated decreased cardiovascular events or mortality with testosterone therapy. A recent systematic review found some evidence of benefit in congestive heart failure and increased time to ST segment depression in exercise testing. The review found inconsistent effects of testosterone therapy on lipids and no beneficial effect on reported angina.

The effects of testosterone therapy on cardiovascular health remain unclear. The FDA has mandated that testosterone product manufacturers conduct a large-scale randomized controlled trial specifically to determine cardiovascular risk, 38 but of any such trial would not be available for years. In the meantime, physicians must counsel patients that the cardiovascular risks and benefits of testosterone therapy are uncertain and should engage in shared decision making.

Contraindications to testosterone therapy are listed in Table 3. Information from references 9 and Because prostate cancer can be stimulated by testosterone, testosterone therapy is contraindicated in patients with known or suspected prostate cancer. There has long been concern that testosterone therapy may increase the risk of developing prostate cancer and increase the symptoms of benign prostatic hyperplasia. However, several meta-analyses of randomized controlled trials have not shown an increased incidence of prostate cancer. Use of supplemental testosterone has been shown to cause a small increase in prostate-specific antigen PSA levels, 52 but the ificance of this increase is questionable.

There also does not appear to be a ificant increase in lower urinary tract symptoms with testosterone therapy, although most studies have excluded men with severe lower urinary tract symptoms at baseline. Testosterone stimulates erythropoiesis, and testosterone therapy in particular the intramuscular esters is associated with an increased risk of polycythemia.

Development of polycythemia during treatment should lead to cessation of therapy, lowering of the dose, or switching to a lower-risk formulation to avoid increased risk of myocardial infarction, stroke, and venous thromboembolism. Testosterone therapy has been shown to increase hemoglobin levels and correct anemia in a ificant portion of older men with anemia of otherwise unknown etiology.

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Testosterone measurement should be considered in older men with unexplained anemia. Based on postmarket reports, in the FDA required manufacturers of testosterone products to add a warning to the drug label about the risk of venous thromboem-bolism. As part of its advisory on cardiovascular risk, the FDA also issued a statement clarifying that testosterone therapy is approved specifically for men with low testosterone levels caused by disorders of the testicles, pituitary gland, or brain that cause hypogonadism i.

Many testosterone formulations are available Table 4 5960and no formulation has superior clinical effects. The selection of formulation requires discussion about administration route, adverse effects, and cost. Completion of a controlled substance contract should be considered before prescribing. Testosterone cypionate Depo-Testosterone.

Testosterone enanthate Delatestryl. Testosterone undecanoate Aveed. Special prescriber registration required because of risk of anaphylaxis and pulmonary oil microembolism. Adverse effects include headache, nasopharyngeal and upper respiratory symptoms. Possible to transfer from one person to another; risk of virilization of exposed women and children. Transdermal patch Androderm.

Applied to axillary area similar to deodorant; risk of transfer to others as with gel forms. Generic listed first, brand in parentheses. Information from references 59 and Men receiving testosterone therapy should be monitored regularly for adverse effects and to ensure normalization of serum testosterone levels Table 5 9. Before initiation of testosterone therapy, testing should include a complete blood count to measure hematocrit, and a PSA test and digital rectal examination to detect preexisting prostate cancer.

An increase in PSA of greater than 1. Baseline; three to six months after initiation of therapy, then annually if stable. Goal is to increase level to midnormal range, although there is no clear target level.

To all the hot men at american family

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