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Ask the Pharmacist

By: Ron and Marla Chapleau
January 10, 2018
 
 

Q: I have been diagnosed with a low testosterone level and was wondering if you had any opinion as to whether one type of treatment is any better than the others?

A: There are many testosterone-replacement options out there (capsules, gels and patches, injections and, most recently, a nasal spray), and we think the vast majority of experts would agree that there is a preferable option for most people from among these various choices.

However, before we get into which choice this is, and why, we thought we’d provide a quick primer on just what testosterone deficiency (TD) is and some other background information regarding this state.

TD, also known as hypogonadism, is a very common condition affecting about 40 per cent of men in the United States over the age of 44 who are seen at their family physician’s office (we could not find Canadian figures but it would be reasonable to assume they are similar). Not at all surprisingly, the incidence increases dramatically with age.

It’s a difficult syndrome to diagnose as its primary symptoms are, to some degree, normal for many of us as we age. Usually, the first symptoms experienced are a decreased desire for sex (i.e. a lower libido), issues with sexual performance and fatigue. There are many other symptoms which may present at the same time or down the road, including increased body fat, loss of strength, hot flushes, loss of body hair (particularly under the armpits and in the groin region), loss of height, a decline in feeling of well-being, irritability, problems with sleep and a host of others.

None of these is specific for TD and many are part of the normal aging process (to a less significant degree). So, for a proper diagnosis, blood work is necessary - a level between 14 and 17.5 Nanomoles per litre (nmol/L) of total testosterone is considered “normal” although some men will experience symptoms at levels just below 15 - as well as a physical assessment.

There are some who meet the diagnostic criteria but should not be treated due to some of the risks that testosterone-replacement therapy carries with it. These include those men with breast cancer and those with metastatic prostate cancer (i.e. prostate cancer that has moved beyond just the prostate) or who have had prostate cancer in the past and are at high risk for it to reoccur.

A fairly recent change in Canada, is that experts now feel that those whose prostate cancer is no longer active and stayed localized only to the prostate, can now be safely treated.

Those with cardiovascular disease are in a bit of a quandary and should consult with their doctor or specialist. Traditionally it was thought that testosterone replacement would, in fact, reduce the risk of cardiovascular incidents (i.e. strokes and heart attacks); however, two recent studies have shown the opposite of this.

Currently, experts are unsure of just what the risks are as they feel there is insufficient evidence to come down strongly one way or the other. The official position is that those with stable cardiovascular disease should be given an adequate trial (this is about three months) of replacement therapy to see if it helps resolve their symptoms and raises their blood levels of testosterone to normal.

As far as which type of product to choose, the vast majority of patients should do better with one of the many patches, gels or solutions (topical) that are applied directly to the skin. That's because they have the advantage of providing continuous absorption over a 24-hour period.

This most closely resembles the testosterone levels that are normally found within the human body as compared to the other dosage forms. Topicals are also less likely to bother the stomach (the capsule form is associated with various stomach issues) and have had years of testing for safety.

The disadvantage of skin application is that it may rub off on others who brush against us and some people have skin reactions to these products, usually in the form of an itchy rash.

The nasal gel does not have these downsides but is more inconvenient (it requires three-times-per-day dosing versus just once-per-day for topicals) and may irritate the nose. It is also a newer product so there is still a lack of long-term data regarding its effectiveness and safety.

The oral form is less successful at maintaining normal testosterone levels than the topicals as levels tend to rise and fall rapidly (it’s taken twice per day because of this) and some men do not seem to absorb these capsules very well.

The two injectable forms have really fallen out of favour with experts due to the inconvenience of requiring a needle (every two to four weeks depending on the product chosen) along with unreliable absorption and fluctuating testosterone levels (many are feeling as if they are low again in the days leading up to their next injection).

As to which of the gels or patches you should choose, the choice is pretty much based on individual preference as they all seem to work about the same.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/?fref=ts

 

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