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Keith T. Chumley, M.D. Men’s Sexual Health-It’s Not Just a Pill Low Testosterone

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Keith T. Chumley, M.D.

•  Board Certified Family Practitioner •  M.S. Human Physiology – Georgetown University •  M.D. Georgetown University

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Goals

•  Understand that there are secondary causes of low testosterone

•  Testosterone treatment requires monitoring •  The best way to maintain normal sexual health is to stay

in shape!

Normal  Sexual  Func1on  

Hormones  

Psychology  Cardiovascular  

Func1on  

Neurologic  Func1on  

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“Doc,  Our  sex  life  is  not  what  it  used  to  be.    Must  be  my  testosterone”  

HYPOGONADISM DEFINITION

•  Failure of the testes to produce androgen (testosterone) or sperm or both

•  TMMC 240 ng/dl - 950 ng/dl

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Primary vs Secondary Hypogonadism(Low T) •  Primary is loss of testicular function

•  NORMAL to lose 1-2% testosterone production/year after age 30

•  Secondary is loss of pituitary or hypothalamic function

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Testosterone function

•  Secondary male sex characteristics •  Changes in muscle/fat distribution •  Bone growth •  Laryngeal enlargement (Adam’s apple/voice) •  Testicular growth •  #PUBERTY

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Testosterone function

•  Homeostatic functions •  Libido •  Bone density •  Erythropoiesis •  Prostate health

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Hypogonadism Causes

•  Loss of Leydig cells over time is normal but by itself does not usually cause low testosterone

•  COPD •  Diabetes •  Hemochromatosis •  HIV •  Medication (e.g. Lupron)

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Hypogonadism Causes

•  Obesity •  Pituitary Mass •  Psychological stress •  Kidney Failure •  ?Chronic Marijuana use •  ?Obstructive Sleep Apnea

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Clinical Presentation

•  Mood Changes (depression/fatigue/anger) •  Decreased Body Hair •  Decreased Bone Density •  Decreased Muscle Mass/Strength •  Increased Visceral Fat •  Infertility •  Decreased libido/Erectile dysfunction

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ADAM Questionnaire

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Laboratory Diagnosis

•  Total Testosterone •  Bioavailable Testosterone •  Free Testosterone

•  Drawn between 8-11 AM •  LH •  Prolactin •  Sex Hormone Binding Globulin 11/19/15   Name  of  Presenta1on   17  

Controversy

•  Most labs do not provide age based results •  What are the target levels?

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Treatment

•  Treat Primary causes first! •  Contraindications

•  Prostate Cancer •  Male breast Cancer •  Obstructive Uropathy

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Treatment

•  Testosterone Injections •  Upside-most cost effective •  Downside-Not physiologic & OUCH!

•  Patch •  Upside-physiologic •  Downside-expensive, rash

•  Transdermal/gel •  Upside-physiologic •  Downside-expensive, risk of transfer to close contact

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Risks

•  Fluid Retention •  Polycythemia •  Prostate disease •  Sleep Apnea •  Personality changes •  ?Coronary Artery Disease •  ?Breast Development •  ?Suppression of Natural testosterone Production

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Monitoring

•  Voiding history •  Blood Pressure •  Prostate Exam •  Obstructive Sleep Apnea symptoms •  Prostate Specific Antigen •  Lipid Profile •  CBC •  Liver Enzymes

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Monitoring

•  Check levels in 2-3 weeks if gel/patch or 8 weeks if injectable

•  Check level halfway in between doses •  Recheck in 3 months •  Every 6 months thereafter

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Other Treatments

•  PDE5 inhibitors •  Viagra •  Levitra •  Cialis

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Other Treatments

•  External Constriction Devices

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Other Treatments

•  Vacuum Pump

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Other Treatments

•  MUSE (Medicated Urethral System for Erections) •  PDE1 inhibitor

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Other Treatments

•  Penile Implants

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Other Treatments

•  Intracavernosal Injections

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The End

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