I am 44 years old.  I have been on testosterone replacement therapy
for four years now and increasingly I just don't feel right.  I often
feel aggressive and quite irritable, and I often  experience a low
libido and a decrease in
erectile function, which I thought the therapy was supposed to cure. 
To top it all off, I have noted both testicular and penile atrophy --
this is VERY discouraging.  Despite no changes in my diet, I also have
been gaining a lot of fat around my abdomen that I cannot lose no
matter how much I exercise.  Lately my voice has also gotten higher. 
My MD routinely orders a testosterone level that shows I am in
"normal" range and he leaves it at that, but things
do not feel at all normal to me.  This is rather distressing -- can
you tell me what is going on?

---

Request for Question Clarification by sublime1-ga on 05 Feb 2006 14:33 PST

skyhawk8...

This quote from the Pituitary Foundation, in an article by 
Ms Theresa Brothwood and Dr Pierre Bouloux, at the Royal 
Free Hospital, London, sums up your situation:

"Sometimes testosterone replacement may not live up to
 expectations, for example, with respect to increasing
 libido and sexual performance. It is important to bear
 in mind that other factors may influence these (e.g.
 other health problems). For this reason a full discussion
 with the endocrinologist of what can be expected from
 treatment at an individual level is invaluable. Review
 of physical, psychological and social responses together
 with regular monitoring of testosterone levels can then
 go towards gaining the most benefit from treatment. If
 sexual performance continues to be a problem, then it
 is reasonable to ask for an independent assessment of
 this from the endocrinologist or by referral to an
 urologist."
http://www.pituitary.org.uk/newsletter/drugs/29-medmatters.htm


Also, effects will vary depending on the method utilized:

"If fertility is desired, injections of LH and FSH-like
 substances (hCG and hMG) are used instead of testosterone.
 These have to be given by intramuscular injections 2-3
 times per week and the effects monitored carefully. It
 may take up to 18 months to achieve sperm production.
 In males not desiring fertility, testosterone can be
 given orally (three times daily), by transdermal patches
 (replaced every 24hours) or as a gel called Testogel
 (Schering UK) which is applied to the skin every 24
 hours. Testosterone can also be given as intramuscular
 injections (which last from 1-3 weeks) or as sub-dermal
 implants (pellets inserted beneath the skin which last
 4-6 months). All these methods differ in their ease,
 convenience of use and unwanted side effects. In practice,
 intramuscular injections or sub-dermal implants tend to be
 the treatment of choice for most men."
http://www.pituitary.org.uk/newsletter/drugs/29-medmatters.htm

Which form of treatment are you receiving?


You should also be aware that aerobic exercise will not
assist the body in producing testosterone. Anaerobic
exercise such as weight lifting with large amounts of 
weight and low reps will both increase your metabolism
(even while you're sleeping) and assist the body in
producing testosterone.

Let me know your thoughts, and what else you need to
consider your question to be suitably answered.

sublime1-ga

---

Clarification of Question by skyhawk8-ga on 05 Feb 2006 16:03 PST

Thanks for the information that you have supplied so far.  With regard
to your question about the form of testosterone I am taking, I am
applying testosterone gel daily as prescribed (Androgel -- a common
brand in the USA).

I am most concerned about the following three symptoms/side-effects:

1. Penile atrophy, a concern which my MD was not very attentive to,
and which he does not seem to be able to answer -- he told me that he
is accustomed to seeing testicular atrophy under this treatment, but
not penile atrophy.
2. Unexplained fat gain around my abdomen with no dietary changes and
despite much aerobic (a fat-fighting exercise) AND anerobic exercise. 
Also, my breasts, which are a bit soft, sensitive, and large for a
male, are resistant to soft tissue reduction even with a lot of
pectoral exercises. And,
3. Lately my voice has gotten higher.

Help!

Thanks.

skyhawk8...

Thanks for letting me know the medication you're using.
As noted in what I already posted, gels are normally 
used for "males not desiring fertility", whereas to
restore fertility, injections are more common.

Let me add the following to what I've already provided.

Okay, first of all, some of the side effects you're experiencing
are listed as possible side effects for Androgel, on Healthsquare:

"More common side effects may include:
 Acne, application site reaction, *breast enlargement*, *emotional
 instability*, headache, high blood pressure, prostate disorder"

Emotional instability can also be described as emotional lability,
and, in your terms, aggressiveness and irritability.

"Less common side effects may include:
 Breast pain, *decreased sexual desire*, depression, difficult
 urination, disorder of taste or smell, hair loss, hot flashes,
 insomnia, nervousness, male reproductive gland disorder,
 swelling of the hands, ankles, or feet, teary eyes, weakness"
http://www.healthsquare.com/newrx/and1559.htm

I added asterisks to emphasize certain pertinent effects.


Second of all, excess aerobic exercise can decrease muscle,
as noted in this article on the Phil Kaplan site:

"If you exercise aerobically, beyond your body's ability
 to provide regular fuel, the body reaches into muscle
 tissue and as you lose weight, you lose muscle!"
http://www.philkaplan.com/thefitnesstruth/aerobics.htm

So I'd suggest no more than about 12 minutes a day of
aerobic exercise, with the rest being weightlifting with
low reps. The more muscle you have, the higher your
metabolism will be, and the more fat you'll burn. Low
rep weightlifting will build muscle better than anything,
and this will increase your body's ability to produce
testosterone.


Part of the problem is addressed in multiple posts on 
the Men's Health Bulletin Boards (these may take awhile
to load). The instructions for Androgel prohibit applying
it to the sex organs, and some people ask why that is,
and orion answers:

"Androgel is formulated to absorb slowly over several hours
 thus closely approximating your normal daily testosterone
 cycle. Applying the gel to your testicles will result in
 rapid absorption giving you a high testosterone level
 followed by a steep decline. Such spikes in testosterone
 are not advisable and can cause several side effects
 including impotence and breast enlargement. Follow the
 direction!"

Assuming you're applying it to the arms and abdomen, as
suggested, it may be that you're still experiencing too
rapid of an absorption rate, producing the spikes and
results noted above.

Even so, JinL also notes:

"When you first start Androgel or any tetsosterone supplement
 you get a boost for about 3 weeks. "Everything" feels better.
 Then you decline to about where you were before. This is
 because your testicles were producing a little bit of
 testosterone then the HRT told the pituritary that you had
 enough "T" & it shut down the testicle production of "T" &
 sperm.. Thus you backslid on your testosterone levels. The
 "T" levels should be in the upper third of the normal range.
 The lower third is for guys over 80.

 If you include some low dose HCG [human chorionic gonadotropin]
 injections every other day it might keep the natural "T"
 production by the testicles, ask your doctor.

 Read "The Testosterone Syndrome by Eugene Shippen"
[http://www.amazon.com/gp/product/0962741817/002-6311027-1848859?v=glance&n=283155]

 If you plan on any more children then find a doc that will
 let you try HCG before doing much testosterone supplements,
 as the "T" shuts down the sperm & testosterone production.

 Also ask him about getting a prescription for compounded
 testosterone. If he does not try you on HCG you will
 probably need a higher dose than Androgel. The compounded
 testosterone that is twice as strong as Androgel is about
 1/4 the price of Androgel.

 You also need to keep getting the hormones tested every few
 months, make sure you get the estrogen E2 tested, if it gets
 too high you will grow breasts. An OTC pill, DIM can lower
 the Estrogen E2 if taken with vitiman E & Zinc"
More posts on the page:
http://www.healthboards.com/boards/archive/index.php/t-71698.html


DIM is Diindolylmethane. The following formulation includes
Vitamin E, but not zinc:
http://www.iherb.com/dim2.html


I didn't find anything specifically discussing penile atrophy,
but certainly that and your voice getting higher are consistent
with what we've seen, which suggests that your estrogen E2 level
is too high, which can result in gynecomastia, or enlargement of
the breasts in men, which is one of the more common side effects
of Androgel, as noted earlier.

I think you should certainly feel entitled to discuss this
further with your doctor, and if he is unresponsive, seek
a second opinion. It's his practice, but it's your body.


Please do not rate this answer until you are satisfied that  
the answer cannot be improved upon by way of a dialog  
established through the "Request for Clarification" process. 

sublime1-ga


Additional information may be found from an exploration of
the links resulting from the Google searches outlined below.

Searches done, via Google:

androgel "side effects"
://www.google.com/search?q=androgel+%22side+effects%22

"aerobic exercise" fat
://www.google.com/search?q=%22aerobic+exercise%22+fat

penis androgel
://www.google.com/search?q=penis+androgel

define:hcg
://www.google.com/search?q=define%3Ahcg

"The Testosterone Syndrome by Eugene Shippen"
://www.google.com/search?q=%22The+Testosterone+Syndrome+by+Eugene+Shippen%22

DIM tabs -guitar
://www.google.com/search?q=DIM+tabs+-guitar

Diindolylmethane
://www.google.com/search?q=Diindolylmethane

"estrogen E2"
://www.google.com/search?q=%22estrogen+E2%22

---

Request for Answer Clarification by skyhawk8-ga on 05 Feb 2006 21:35 PST

Thank you so much for your very informative reply.  I hope that you
can clarify two points:

1. Aerobic exercise -- You have recommended 12 minutes of aerobic
exercise.  I am trying to understand this because it is so contrary to
everything else that I have read and heard about aerobic exercise and
"fat burning".  I have heard almost universally that aerobic exercise
is of no benefit at all for weight and fat reduction if it is not of a
long duration, say 30-45+ minutes.  All aerobic machines at the gyms
include a "Fat Burn" setting that features a low speed and very long
duration.  I've heard that fat burning only begins to occur after at
least 30-40 mintues of aerobic exercise.  A. Can you elaborate on your
recommendation of 12 minutes in light of my desire to burn the fat
around my abdomen?  B. Is there any possibility that a high estrogen
level is contributing to my abdominal fat?

2. The estrogen test that you refer to.  I live in the USA and I use
LabCorps for my testing.  What is the exact medical name of this
estrogen test?  Is this name universally used and/or recognized by all
USA physicians and lab testing facilities?

Many thanks in advance for clarifying these two issues.

---

Clarification of Answer by sublime1-ga on 06 Feb 2006 11:41 PST

skyhawk8...

You wrote:

1. Aerobic exercise -- You have recommended 12 minutes of aerobic
exercise.  I am trying to understand this because it is so contrary to
everything else that I have read and heard about aerobic exercise and
"fat burning".  I have heard almost universally that aerobic exercise
is of no benefit at all for weight and fat reduction if it is not of a
long duration, say 30-45+ minutes.  All aerobic machines at the gyms
include a "Fat Burn" setting that features a low speed and very long
duration.  I've heard that fat burning only begins to occur after at
least 30-40 mintues of aerobic exercise.  A. Can you elaborate on your
recommendation of 12 minutes in light of my desire to burn the fat
around my abdomen?  B. Is there any possibility that a high estrogen
level is contributing to my abdominal fat?

---

First, let me note that this is beyond the scope of the original
question, and amounts to an additional question, so I would prefer
to be succinct here, while pointing you in the right direction.

The 12-minute figure was based on the link I posted, from the 
Phil Kaplan website:

"Many women make the mistake of undereating and over-aerobicizing!
 If you exercise aerobically, beyond your body's ability to provide
 regular fuel, the body reaches into muscle tissue and as you lose
 weight, you lose muscle!

 People who get started on my program begin by performing
 only 12 minutes of aerobic exercise per day....and they
 lose fat! The reason is twofold. Firstly, they develop
 a nutritional concern for supplying the material for muscle
 maintenance, and secondly, their aerobic exercise is
 customized so it keeps them within their fat burning limits. 

 By losing muscle through aerobic exercise, you then become
 dependent on that exercise just to maintain the condition
 you're in. Take a break from the aerobics and your body will
 rapidly accumulate new fat stores."

Read the whole page here:
http://www.philkaplan.com/thefitnesstruth/aerobics.htm


Another writer, Dr. Bernarr, D.C. D.D., has this to say:

"If you vigorously exercise before you eat, you will eat less."
[A good time for so-called aerobic exercise, but done in an
anaerobic way, such as wind sprints vs an hour on the treadmill
at a long-distance running pace].

"Lean muscle has the highest resting metabolic (calorie burning)
 rate of any tissue. The more muscle you have, the more calories
 you burn, day and night! Muscle burns calories even at rest,
 while fat tissue is virtually dead weight."

[...]

"To lose weight, do as little aerobic exercises as you can.
 Aerobic exercises (with oxygen), do not help you to lose weight.
 Aerobic exercise only helps you gain endurance and will take you
 forever to burn up your fat." [As you've noted, with the added
 risk that you'll start losing muscle mass.]

[...]

"To lose weight and fat, do anaerobic exercises (not using oxygen,
 without oxygen). Anaerobic exercises are sprinting, running up
 stairs rapidly, jumping high, long and vertically with intensity,
 rapid cycling, rapid rowing, rapid swimming, weight throwing,
 weight lifting with low repetitions, hand balancing, gymnastics,
 chins, parallel bar dips, roman rings, rope climbing, tubing,
 bands, pulleys, wrestling and martial arts. [He leaves out
 rapid jump-roping].

 Anaerobic exercises are intense exercises that can be tolerated
 for only a few moments. They are short bursts of all out
 activities. They are activities using muscle groups at high
 intensities that exceed the body's capacity to use oxygen to
 supply energy. They create an oxygen debt by using energy
 produced without oxygen. They are activities in which oxygen
 demands of muscles are so high that they rely upon an internal
 metabolic process for oxygen."

Much more on the page:
http://www.healself.org/weight.html


As for your weight gain being related being related to estrogen,
I would say it's more likely that, since Androgel decreases your
body's production of testosterone, this is similar to the weight
gain many animals demonstrate after being spayed or castrated.

Once your stores of fat begin to increase, fat itself produces
an increase in estrogen, per this article on fat from AskMen:

"Carrying a few extra pounds may also wreak havoc on your
 hormonal balance, leading to a variety of illnesses and
 health risks. Estrogen, the classified 'female hormone,'
 is a fat-storing hormone that is also naturally present
 in small amounts in men. But when you gain weight, estrogen
 levels rise and other health problems ensue.

 Although estrogen is necessary in men, as it regulates a
 healthy libido, improves brain function (especially memory)
 and protects the heart, when the levels are too high,
 testosterone levels are reduced, and many men experience
 fatigue, muscle tone loss, decreased sexual function, and
 in some cases, enlarged prostates. In other words, there
 are no good side effects to increased estrogen levels in men."

Much more in the multi-page article:
http://www.askmen.com/sports/foodcourt_100/143_eating_well.html

-------------------------------------------------------------------

2. The estrogen test that you refer to.  I live in the USA and I use
LabCorps for my testing.  What is the exact medical name of this
estrogen test?  Is this name universally used and/or recognized by all
USA physicians and lab testing facilities?

---

E2 Estrogen testing will be understood by your doctor. Estrogen 
is commonly tested as follows:

"Estrogen fractions (over 30 different forms of estrogen have been
 described; the most common forms tested are estrone [E1], estradiol
 [estradiol-17 beta, E2], and estriol [E3])"
http://www.labtestsonline.org/understanding/analytes/estrogen/test.html

So if you tell your doctor you want to be tested for estradiol,
or estradiol-17 beta, if you want to impress him, he can order
tests specific to this variant.

sublime1-ga


Additional searches done, via Google:

"increased estrogen" "weight gain"
://www.google.com/search?q=%22increased+estrogen%22+%22weight+gain%22

E2 estrogen test
://www.google.com/search?q=E2+estrogen+test

Very thorough, thoughtful answers to some rather difficult, complex questions.

skyhawk8...

Thanks very much for the rating and the tip!

sublime1-ga

I would recommend reviewing The Science of Sex (www.sexualtips.net)
for detailied information on improving libido and role of hormones.
More importantly, I would suggest finding an endocrinologist who
treats you as more than a lab number. A lab result shows where you
fall in a statistical range, however this means little to you
personally. What is "normal" for you is what relieves your symptoms.
Your testosterone levels could show as normal, yet your body's
testosterone receptors are not taking up enough.

While I am not a doctor, it is the testosterone/estrogen ration that
is important, and your symptoms scream "too much estrogen". The
problem with testosterone replacement therapy is that the body can
convert the testosterone into estrogen, particular if you carry a good
amount of body fat (and particularly abdominal fat). Fat tissue
converts testosterone into estrogen, so you have a vicious cycle:
higher estrogen leads to more fat deposition, which results in more
conversion to estrogen. Estrogen competes with testosterone for
receptor uptake.

Penile shrinkage is related to a shortage of (or a shortage of uptake
of) DHT, dihydrotestosterone. The irritability you describe is also a
classic case of whacked TER (testosterone/estrogen ratio). Fortunately
this can all be reversed. I recommend the Science of Sex book as by
far the most thorough and detailed discussion of all this. You need to
take measures to reduce your estrogen level (you need to get the fat
off!), the book has a great deal of information on this, and you need
to find a more responsive endocrinologist who understands this and/or
is willing to work with you until your TER is normal. Don't despair,
this is correctable if you are motivated. Best of luck.

Hello skyhawk8-ga,

I've been hard at work for the past two days on your question about
hypopituitarism and I've got several answers for you, but your
question seems to have disappeared! I've got the research all put
together, written up, and organized for you. I'm trying to contact you
via this older question of yours. Please let me know if you meant to
withdraw your question. I'm happy to post my research for you.

Sincerely,
Boquinha-ga