טוסטוסטרון

שלום בן 40 עם רמות נמוכות של טסטוסטרון (כנראה שאין בעיה באשכים ו/או בבלוטת יותרת המוח) הוצע לי בעבר טיפול בטסטוסטרון (לא דובר אז על משהו ספציפי), אך העדפתי שלא. לאחרונה אני חושב על זה, בין השאר גם מהבחינה של המשקל, אני חושב שיש קשר בין ההשמנה וחוסר היכולת שלי לרדת במשקל לירידה בטסטוסטרון . רציתי בבקשה לשאול: 1. האם יש עדיפות למי מהתכשירים (כדורים/זריקות/ג/ל) מבחינת הסיכונים ותופעות הלוואי? 2. האם אכן יש סיכון למחלות לב ושבץ מוחי בטיפול בטסטוסטרון? 3. יש הגיון בלנסות במקרה שלי טיפול בטסטוסטרון על מנת לראות האם זה הגורם להשמנה? תוך כמה זמן אפשר יהיה לבחון את זה? תודה רבה ולילה טוב

אני מצרף לך מאמר שפורסם לאחרונה עי אחד האנשים המובילים בתחום. מאמר באנגלית. אם שי בעיה עם הבנתצ דברים אתה מזומן לזחור אלי. בברכה, דר דדשב הנה: Testosterone levels decline with age and chronic illness. In addition, the symptoms of hypogonadism overlap with those of many chronic conditions prevalent in older men. It is thus common to see older men with nonspecific symptoms and a low testosterone level. Also, we do not have good prospective data on long-term cardiovascular risks associated with testosterone. For all these reasons, testosterone therapy in older men remains controversial. In an older man with low testosterone, the first task is to ensure that a diagnosis of hypogonadism has been established. Are there symptoms of hypogonadism? If the patient is not experiencing hypogonadal symptoms, testosterone replacement is not indicated. I always confirm a low testosterone level with a second measurement taken in the morning after fasting. Testosterone is markedly reduced during acute illnesses and returns to normal over weeks to months after recovery. If there was a recent hospitalization, I wait 3 months to repeat a testosterone level. Conditions that alter sex hormone–binding globulin (SHBG) are common in older men. I always obtain a SHBG measurement and calculate free testosterone. If free testosterone is normal, the patient does not have hypogonadism, and testosterone therapy is not indicated. Erectile dysfunction in the absence of other sexual symptoms is not a symptom of hypogonadism. In these cases, a trial of a PDE5 inhibitor is usually indicated, not measurement of testosterone. While functional declines of testosterone due to chronic diseases or aging are common in older men, diseases of the pituitary–gonadal axis occasionally occur and should not be overlooked. Is the testicular exam abnormal? Gonadotropins (FSH and LH) need to be checked to distinguish primary from secondary hypogonadism. These need to be measured before any replacement is given. Older men with age- and comorbidity-related declines in testosterone usually have gonadotropins in the normal range and only modestly reduced testosterone. If gonadotropins are outside the normal range, free testosterone is very low, or there are abnormal testicular exam findings, consider specialty referral. Once hypogonadism has been confirmed, testosterone replacement may be considered. With older men, it is important to discuss the unknown cardiovascular risks of testosterone before initiating therapy. It is also important to document the symptoms being attributed to hypogonadism so that effects of therapy can be followed. Specific contraindications to testosterone replacement include the following: Prostate cancer, undiagnosed prostate nodules, elevated PSA, or an increase in PSA that has not been evaluated; Breast cancer; Polycythemia; Untreated obstructive sleep apnea; Severe lower urinary symptoms; and Poorly controlled congestive heart failure. Several testosterone formulations are available. The most commonly used include the following: Topical gels, which are dosed daily and produce uniform testosterone levels. Care needs to be taken to avoid exposing women and children to topical testosterone. Transdermal patches also provide steady testosterone levels. Skin irritation is a frequent problem. Intramuscular testosterone dosed every 2 weeks is the least expensive option. Some patients develop symptoms related to fluctuation of testosterone levels between injections and require a lower dose administered weekly. Testosterone therapy should be monitored. In men using gels or patches, testosterone may be measured 3 to 12 hours after application. Levels in men using intramuscular testosterone should be checked midway between injections. In older men, I titrate to a calculated free testosterone level in what is the lower to mid–normal range for a younger man. Men on testosterone replacement should also be monitored for complications of therapy and development of contraindications to testosterone replacement. It is particularly important to assess after 4 to 6 months whether the symptoms attributed to low testosterone have improved. If they have not improved, testosterone therapy is providing no benefit and should be discontinued.