TESTOSTERONE REPLACEMENT

Testosterone levels supposedly decrease an average of 1% per year in men after age 30.  However, there is great variation in the rate of decrease as well as when it occurs.  In any case, the situation is nothing like menopause in women, where hormone levels crash over just a year or two.

Testosterone is important for maintenance of muscle mass and prevention of fat accumulation.  It of course affects the brain, but not just in producing libido (sex drive).  It also is a factor in mental acuity.  It is important to bone density the same way estrogen is in women; i.e. low testosterone can produce osteoporosis (low calcium in bones, which increases the risk of fracture).  The blood vessels supplying the penis are to some degree testosterone dependent, just like the blood vessels around the urethra in women are estrogen dependent.  The first step in treating erectile dysfunction is to check testosterone levels (as well as estrogen, and prolactin).  A baseline PSA should be obtained in men over 40. The first sign of cholesterol problems can be erectile dysfunction, so your cholesterol also needs to be reviewed. 

 A minimum testosterone level is considered to be 400.  The average testosterone level in young men is 700.  Some men will need a level of up to 900 to feel right. 

Replacement is best done with pellets. Injections of Depo-Testosterone are a poor choice.  The typical injection dose is 100 mg per week, which in 16 weeks amounts to 1600 mg.  Yet I place 800 mg of pellets for 16 weeks.  Where does the extra testosterone in the injections go?  Into spikes in blood levels that result in testosterone being transformed into estrogen.  This produces gynecomastia (“man-boobs”) and prostate enlargement.  There are FDA approved pellets of 3.2 mm diameter (Testopel) which last 11 weeks or so and might be covered by your insurance.  If your are willing to come in every 11 weeks for pellet placement (either in the love handles or, if you are thin, parallel to and below the last rib), then these are worth considering.  I have compounded pellets available which are 4 mm diameter and last 16 weeks.  Most patients prefer the fewer visits per year and, if they don't have insurance coverage, the significantly lower price.  All pellets are simply pure testosterone, compressed and then autoclaved (sterilized at high temperature).  There is no filler, no tube that has to be removed later. 

You need to take the following as long as you are on testosterone replacement:
Propecia (finasteride 1 mg).  This prevents the conversion of testosterone to dihydrotestosterone (DHT).  DHT causes balding and also causes prostate enlargement. PSA levels are 40% lower on Propecia; let anyone who checks your PSA know take it.
Zinc.  This prevents the conversion of testosterone to estrogen.  For zinc citrate, which is probably better absorbed, I recommend 25 mg daily.  For other salts of zinc, I recommend 50 mg daily. 
Calcium with Vitamin D.  This will maintain your bone density.  You benefit much more from calcium when your testosterone level is normal.  Calcium citrate is better absorbed than calcium carbonate.  I recommend Citracal Petites, two tablets twice daily or, if you can’t remember twice daily, then three tablets once daily. 
Vitamin C.  This is important to the production of collagen, which is the matrix upon which calcium lies in your bones.  The addition of 250 mg per day reduced hip fractures 44% in women over age 75.  (Men are not as susceptible to hip fractures because their hormone levels don’t go to near-zero, so they don’t get studied.  However, 20% of hip fractures are in men and there would be more if they lived as long as women.)

 

ERECTILE  DYFUNCTION

Difficulty getting or sustaining an erection is overall, an age-related problem, becoming an intermittent or regular problem in men over 50.  (Delayed ejaculation may also be a problem, particularly after age 55.) 

Many drugs are associated with erectile dysfunction or delayed ejaculation.  The Prozac family of SSRI anti-depressants is famous for interfering with orgasm both in men and women.  Many of the anti-hypertensive drugs interfere with erection or ejaculation (orgasm).  Alcohol is a common culprit too.

After ruling out drugs as a factor, the first step in management is to check your testosterone level and if it is not over 450, start you on testosterone replacement.  If your cholesterol hasn't been checked, it needs to be, because your problem could be that the blood vessels to your penis are plugged up.  If your wife has become unattractive to you or you just don't like her any more, remember, “the penis is the first to know.”  It can be mutual.  If you drink beer and watch TV until 10 PM and then stand up and say “hey, let's do it,” sex is not likely to work out very well.  Her arousal is part of your arousal.

Drugs to help you get an erection (when aroused):
Viagra (generic name silendafil) was the first to become available.  Viagra may delay ejaculation, which could be a problem for some men.   It also has a short duration of action.  It really doesn't last more than two hours if you take it on an empty stomach.  It's absorbed then excreted.  In this circumstance, you'd better plan on having sex 45 minutes to 2 hours from the time you take it.  The typical dose on an empty stomach is 50 mg.  100 mg taken a 10 to 15 minutes before a meal is more slowly absorbed and the effect is maximum 2 hours to 4 hours from the time you take it.  The silendafil from India (trade name Suhagra) seems to be more slowly absorbed than Viagra.  It should only be taken on an empty stomach (wait at least 30 minute to eat), 100 mg is the typical dose, and it can be considered effective 1 hour after taking until about 3 hours after taking.  Nasal congestion is a side-effect of all the drugs in this class (there is erectile tissue in the nose).  Since Viagra wears off rapidly, you are less likely to snore with it.  Headache and nasal congestion are the significant side effects.  Don't take Sudafed (pseudoephedrine) for the nasal congestion; it is a treatment for priapism (persistent erection: over 4 hours of continuous erection can deprive the penis of blood flow and damage it).  This means that Sudafed can also interfere with an erection you want to have.
Levitra is an also-ran.  Because of this, its manufacturer has negotiated with the insurance companies and it is often covered (6 or 8 a month) when the other two aren't.  It's the least potent of the three but does have a duration of action longer than Viagra and seems to be absorbed more quickly than Cialis.
Cialis (tadalafil) is a long duration drug related to Viagra.  Unlike Viagra, it does not significantly delay ejaculation.  Although the company claims Cialis can start working in as little as 30 minutes, my patients tell me they take it early afternoon to have maximal effect in the evening.  It may still be working the next morning. 
If you have side effects then you won't like Cialis because of the long duration of the side effects (headache, nasal congestion, back pain).  If you don't have side effects you will be happy with it except for its price.  It runs about $10 per tablet and many men don’t like spending that without knowing what lies ahead in the evening.  A solution is to purchase it from India for $5 per tablet (I recommend blueskydrugs.com).  If taken for the first time in 48 hours, the dose is 10 to 20 mg.  Taken daily, 7 to 14 mg is usually enough because some is left in your system from the day before.  In fact, the manufacturer recommends 2.5 or 5 mg for daily use, but my patients haven’t found such low doses effective.  The brand name tablets aren’t symmetrical, which makes cutting them exactly in half rather difficult, but that’s the manufacturer’s intent.  You will want to get the 20 mg tablets and cut them in halves or thirds or whatever, as they are the same price as 10 mg tablets.
WARNING: DO NOT TAKE ANY OF THE ABOVE DRUGS WITH NITRATES, OFTEN PRESCRIBED FOR CHEST PAIN (ANGINA) OR FOR HEART FAILURE.  IF IN DOUBT, ASK YOUR PHYSICIAN.

Drugs that work even without arousal (and can work even if Viagra doesn’t):
Caverject (prostaglandin E or alphaprostil) is injected into the penis with an insulin syringe.  The patent has expired on its ingredient, so I have multi-dose vials made up, also containing phentolamine, another erection-producing drug.  (I charge $200 for the vial, which is enough for 15 to 40 erections depending on the dose you require).  I do not recommend papaverine, which seems to increase the risk of penile fibrosis (see below).  There are now extremely tiny needles on insulin syringes (31 gauge), so I think injections are worth considering for men who didn’t get a satisfactory result from any of the three Viagra-type drugs, or for those who have extreme anxiety about sexual performance and want a guaranteed erection.  You will first need to work out a proper dose, starting low.  The goal is an erection that lasts through sex but not much longer.  Priapism, an unusually sustained erection, can permanently harm the penis.  Four hours is considered the danger point.
The only risk of penile injections, other than priapism or bruising, is penile fibrosis.  This is scarring at the injection site.  Personally, I think the silicone lubricant in the syringes may be a factor, but I have never heard any one else suggest that, and silicone-free insulin syringes are not available. To minimize silicone pick-up from the syringe, I advise that the drug only be drawn up into the syringe immediately prior to injection.  Also, 0.5 ml syringes are advisable because their plunger is smaller diameter.  If you need more than 0.5 ml I can have a more concentrated mix made.  Whatever the cause of scarring, the concern about it makes injections a second choice after the Viagra family of drugs. 

PREVENTING MALE BALDING:  PROPECIA, ROGAINE

There are two drugs that can be helpful in slowing the progression of baldness, Rogaine and Propecia.

Propecia (finasteride) is taken by mouth.  It blocks the conversion of testosterone to dihydrotestosterone (DHT) in the hair follicle.  In hair follicles, DHT is several times more potent than testosterone. Men (and some women) who are going bald are converting more testosterone to DHT in their hair follicles; they don’t have more testosterone.  Balding is a progressive process.  Hair shafts become thinner, then the hair reverts to a thing short “baby hair.”  Then there is no growth but if you look at pores there is still some hair color in them.  Propecia will reverse the process.  At the top of the head this process proceeds more slowly than at the frontal hairline, so Propecia does better at regrowing hair there.  After a year of use, most men can expect the top of their head to look like it did five years ago.  Propecia works very well at preventing further hair loss everywhere on the head. 
Propecia also blocks conversion of testosterone to DHT in the prostate gland in men, and in fact is sold for treating enlarged prostates under the brand name Proscar.  It’s the same drug but Proscar is 5 mg and Propecia is 1 mg.  Still, even Propecia 1 mg will shrink the prostate, an average of 27%.  This does mean a bit less semen gets produced per day.  But the semen released in an ejaculation is stored up in the seminal vesicles, and it usually doesn’t matter if it takes the seminal vesicles 27% longer to fill up.  Thus, only 3% of men complain of any side effects from Propecia in the first year, and even these men have no side effects if they continue to use Propecia.  Since testosterone itself isn’t affected, sex drive and erection don’t change. 

Rogaine (minoxidil) is applied to the scalp.  It is now available as foam, which is less messy.  It can be used indefinitely.  It's not as effective as Propecia.  I like to see it used the first six months that someone is on Propecia, to do everything possible to get miniaturized follicles growing again.  For hair transplant patients, I like to see it started two weeks before surgery and used for six months after surgery (starting one week after surgery).  You may find it too messy to use twice daily.  Once daily is still beneficial.

Nizoral (ketoconazole) is also an inhibitor of the conversion of testosterone to DHT, but doesn't have clinical studies proving an effect on scalp hair regrowth/balding prevention.  However, if you have dandruff, it would be logical to choose it over Head and Shoulders.