Testosterone Side Effect Management Table

Problem	Solution and Comments
Acne/oily skin  Caused by Dihydrotestosterone (DHT) effect on increased oil production	·     Accutane – a powerful prescription item - 40 mg/day for one week sometimes stops acne if started at the first sign or as directed by your doctor. Accutane is potentially highly liver toxic. ·     Sporanox – Effective for some acne-like eruptions that are caused by fungi. Some doctors also prescribe antibiotics, like tetracycline, for acne with good results.  ·     Anti-bacterial soaps - Use a scrubbing brush and wash twice a day, especially after sweating during a workout. ·     UV light or sunlight with moderation.
Hair loss  Caused by DHT effect on hair follicles	·     Nizoral shampoo– Available by prescription and over-the counter as a lower dose product. ·     Rogaine – Available by prescription.  ·     Propecia (finesteride) - Available by prescription. A few males experience decreased erections with finesteride
Increased sex drive	·     A problem?  Sex drive is part of quality-of-life. This is not necessarily a bad side effect. Enjoy it.
Unresolved erectile function	·     Viagra, Cialis, Levitra – Available by prescription; enables robust erections. Take an allergy medication and ibuoprofen with it to minimize sinus congestion and headaches.   ·     Yohimbine (Yocon) - Available by prescription; increases sex organ sensitivity. Can increase heart rate and blood pressure ·     Muse - Available by prescription; pellet inserted into the urethra to produce erection. ·     Trimix – Available by prescription. The best and cheapest formula for injection into the penis for lasting erections. Visitwww.apsmeds.com ·     Caverject - Available by prescription. An injection into the penis that produces an erection that can last 1 to 2 hours. Be careful with injecting too much since it can produce dangerously ling erections that need to be treated in emergency rooms! Follow instructions from your urologist.  ·     Papaverine – An older injectable medication, less expensive than Caverject.  ·     Wellbutrin – Prescription at 300 to 450 mg/day; increases dopamine. ·     Human chorionic gonadatropin (HCG) – First dose is 5,000 IU, then 250-500 IU a week. No protocol has been proven in controlled studies yet. Note: If impotence happens while on testosterone, try varying the doses of testosterone. E.g. higher and lower.
Insomnia   Usually this is caused by dosages that are too high. Find the least amount that gives you a good result.	·     Sleeping medications – e.g. Ambien, Sonata, Restoril ·     Melatonin - 1 to 3 mg before bedtime. ·     Avoid working out too close to bedtime. ·     Limit caffeine, especially after 3 pm. ·     Visit houstonbuyersclub.com for a comprehensive sleep formula with tryptophan, melatonin and inositol. Nutrients do not work as well as drugs, but they can help some people.
Sleep Apnea	·     Have a sleep specialist prescribe a sleep study. Some people may have to wear a C-PAP machine to breathe at night. Visit http://www.sleepapnea.org/ for more information
Testicular atrophy	·     Human Chorionic Gonadotropin (hCG)– One 5,000 unit injection per week for 2 weeks, followed by maintenance of 250 IU twice a week.  Decrease testosterone dosage accordingly after starting hCG
Enhanced assertiveness	·     Count until 10 and be aware of your interaction with others. ·     Decrease caffeine. ·     Meditation, yoga, breathe from your belly for a few minutes when over reacting. ·     The testosterone dosage may be too high. ·     Make sure your estradiol level is not much over 25 pg/dl
High blood pressure/water retention	·     Blood pressure medications - Elevated blood pressure is usually transient and stops within a few weeks of the end of a steroid cycle. However, ongoing or chronic steroid use is associated with high blood pressure. Try ACE or ACE II inhibitors since they seem to have fewer sexual dysfunction related effects   ·     Supplements – Magnesium (600 mg/day); vitamin B6 (100 to 200 mg/day); may help reduce water retention.  ·     Water - Drink extra water every day to help flush the kidneys.
Gynecomastia (male breast development)  Caused by overproduction of estrogen, which can happen when is there is too much testosterone. (Testosterone converts into estrogen.)	·     Arimidex - Inhibits estrogen production. Available by prescription. 1 mg/day until sensitivity stops, then ½ mg per day. Some people take .5 mg three times a week for maintenance. Ensure that your estradiol is under 20 pg/dl but do not go too low since it is needed for bon, skin and hair health. Some people get it online if doctor does not prescribe.   ·     Nolvadex – Competes with estrogen for receptors. Available by prescription, 10 to 20 mg/day. Not as effective as Arimidex. Use of Nolvadex during a steroid cycle may reduce the net anabolic effect, as it decreases the production of GH[i] and IGF-1. Severe cases may require removal of the breast tissue by surgery. ·     DHT cream- Some people have obtained great results by robbing a 10% DHT cream on their nipples. Ask your compounding pharmacy.  By prescription only. ·     Some cases require surgery if not treated early
Virilization (body hair growth, deepened voice, clitoral growth in women)	·     Women with this problem should ensure that they are using the lowest possible dosage ·     Testosterone replacement in men seems to exacerbate body hair growth in males. ·     Proscar – Available by prescription at 1 to 5 mg/day, for men.
Benign Prostate enlargement	·     Proscar - Available by prescription. For men, 1 to 5 mg/day. (Note: Can cause decreased sex drive and erections in some men.)   ·     Hytrin, Flomax - Available by prescription. ·     Saw palmetto extract – Very effective for reducing prostate problems, but one study suggests that this herb may reduce the effects of testosterone, too.[ii] ·     Estrogen inhibitors like Arimidex. Estrogen dominance appears to increase prostate growth.[iii] [iv] ·     Check your prostate specific antigen and have a digital rectal exam before starting any steroid program, to detect potential for prostate cancer, especially if you are over 35 or have a family history of prostate problems, and have it checked on a regular basis.
Polycythemia (Elevated hematocrit, which means there are too many red blood cells that can increase blood viscosity and cardiovascular risks)	·     Therapeutic phlebotomy means to have a pint or more of blood removed, usually 1 pint per week over several weeks. (1 pint usually will lower hematocrit by about 3 points.) Polycythemia is a compelling reason to avoid using higher steroid doses than are necessary. Taking the lowest effective dose reduces the risk of over-production of hemoglobin (red blood cells).

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[i] Metzger, DL, et al. Estrogen receptor blockade with tamoxifen diminishes growth hormone secretion in boys: evidence for a stimulatory role of endogenous estrogens during male adolescence. J Clin Endocrinol Metab (1994) 79(2):513-518.

[ii] el-Sheikh, MM, et al. The effect of Permixon (saw palmetto) on androgen receptors. J Acta Obstet Gynecol Scand (1988) 67(5):397-399.

[iii] Suzuki, K, et al. Endocrine environment of benign prostatic hyperplasia: prostate size and volume are correlated with serum estrogen concentration. Scand J Urol Nephrol (1995) 29:65-68.

[iv] Gann, PH, et al. A prospective study of plasma hormone levels, nonhormonal factors, and development of benign prostatic hyperplasia. The Prostate (1995) 26:40-49.

Testosterone replacement therapy reduces visceral fat and waist circumference

http://www.epgpatientdirect.org/low-testosterone/latest-updates/testosterone-replacement.cfm

Nelson Vergel's Testosterone Column at MESORx

http://www.mesomorphosis.com/blog/author/nelsonvergel/

Evidence review places benefits, drawbacks of testosterone therapy in context for physicians

Testosterone replacement remains controversial due to a shortage of large clinical trials demonstrating the benefits and adverse effects of treatment in boys and men of all ages. However, available evidence and published clinical experience may help physicians determine for whom this therapy is appropriate. “Treatment of testosterone deficiency due to classical diseases affecting the hypothalamus, pituitary and/or testes has been accepted for decades, although there were no multicenter trials,”Glenn R. Cunningham, MD, and Shivani M. Toma, MD, both of the Baylor College of Medicine and St. Luke’s Episcopal Hospital in Houston, wrote in a recent review. Cunningham, who is also an Endocrine Today editorial board member, and Toma analyzed the currently available data more closely to gain better insight into the treatment’s use. “Most clinicians do not have the time or the expertise to critically review the literature on a complicated medical issue,” Cunningham said in an interview. “A review of this type in a reputable journal should highlight the issues and address them in an informative manner.” Challenges of diagnosis, age Physicians may have trouble determining whether testosterone therapy is appropriate because diagnosing androgen deficiency is complicated, according to the authors. Although several symptoms, including incomplete sexual development and loss of body hair, are apparent, others, such as fatigue, are nonspecific. Serum testosterone levels are also not necessarily reliable as thresholds for different tests vary widely. Moreover, these levels naturally decline with age. “The assumption is that older men who fall below this reference range for younger men will also benefit from replacement testosterone treatment. This argument ignores the fact that we have limited data to assess relative benefit at specific serum testosterone windows,” Ronald Swerdloff, MD, and Christina Wang, MD, both of Harbor-UCLA Medical Center, wrote in an accompanying editorial published in The New England Journal of Medicine. Generally, physicians deem testosterone treatment suitable for boys aged 14 years with delayed puberty and men aged 20 to 49 years as benefits outweigh the risks in these populations. In men aged 50 to 60 years, however, true androgen deficiency is difficult to detect due to common comorbidities, such as obesity and type 2 diabetes, that may lower testosterone levels. For men aged older than 60 years, the debate revolves around whether aging organs are as responsive to testosterone therapy, the researchers said. Benefits, risks Cunningham and Toma said several randomized, placebo-controlled trials back well-known advantages of testosterone therapy, including improvements in body composition, bone mineral density, libido and sexual function. Although linked with various side effects, increased risk for prostate cancer and benign prostatic hyperplasia, and cardiovascular issues are most concerning, Cunningham and Toma said. Current clinical trials indicate little risk for prostate cancer, but the researchers noted that exposure time to testosterone was limited in these studies. Similarly, two meta-analyses suggest no increased risk for CV events, but one study of testosterone use in men aged 65 and older yielded data to the contrary. “An ongoing National Institute of Aging-sponsored clinical trial should provide definitive answers regarding potential benefits [of testosterone replacement therapy],” Cunningham said, noting that if the results confirm benefits, then a larger more expensive trial that can better assess the risks, as well as benefits, will be warranted. Currently, however, Cunningham and Toma advise physicians to proceed with caution. “For now, clinicians should discuss the available efficacy and risk data for testosterone replacement and should help each patient make the decision that is best for him,” they wrote. For more information: Cunningham GR. J Clin Endocrinol Metab. 2011;96:38-52. Swerdloff R. J Clin Endocrinol Metab. 2011;96:62-65.