The use of testosterone supplementation in men and women has gained a lot of attention in the last few years. Clinics for men and women have popped up everywhere. Inevitably, the consumer is bombarded with advertising and claims. This leads to a lot of confusion for the consumer trying to figure out if this treatment is for them.
To try and make sense out of the messages, I offer a few points for your consideration. Here is my take on testosterone (the use of “T” refers to testosterone), written in a Q an A format:
Who Gets Low Testosterone?
The short answer is all of us. Both men and women see a gradual drop in testosterone levels usually starting after age 30. For women the levels drop even quicker after menopause as the ovarian production of testosterone falls right off. The long answer to this question is “How do you define low testosterone?” The “normal range” for testosterone as reported by labs is very broad for men and women. The range of “normal” takes into account men and women over a range of adult ages. Most men feel their best at the upper range of normal. Most post-menopausal women feel their best at or above the upper range of normal. If your regular doctor runs a blood test on your T levels you may well be in the “normal range.” But this does not define your optimal range.
Is Testosterone Safe?
There is a healthy trend towards using bio-identical hormones, exact copies of the hormones that men and women produce. The theory is that bio-identical is more natural and therefore safer. The problem with this statement is that there is no significant body of scientific evidence to back it up. We do know that use of equine (horse) estrogen such as Premarin has been linked to a higher risk for breast cancer. The oldest available form of testosterone is injectable, and it is not bio-identical. Injectable testosterone has a long list of warnings and potential side effects. Today many men and women receive bio-identical cream, gels or pellets. Pellet therapy has become very popular for all the right reasons, but there is a total lack of long term studies to show how safe (or unsafe) it is. The last significant published report on testosterone was done at Veteran Affairs and it showed an increased risk of heart disease in men taking any form of testosterone therapy. The study had many potential flaws, and the accuracy of the results can be questioned.
I believe the honest practitioner using bio-identical T should tell patients that “we don’t know the long term safety.” Yet I see many offices, clinics and med spas claiming that testosterone pellets will protect their heart and brain. There simply is not the evidence to make those claims. Ultimately the decision to use T therapies comes down to a “risk benefit analysis.” If you try testosterone and your quality of life improves then you may choose to continue therapy even though long term safety is unknown.
What is better? – Creams, Gels, Shots or Pellets?
Shots have been around the longest, and each injection lasts an average of 2 weeks (this can vary greatly). The shots are in an oil base and must be injected into buttock muscle. Typically the cost of T injections in the office or at home are covered by insurance companies. Shots are not bio-identical and this is a potential safety concern. After an injection of T, blood levels go high and then taper over the next 2 weeks – meaning that the levels are not even or stable, but follow a “peak/trough” or “roller-coaster” pattern – which is less than ideal.
Creams and gels containing T are applied to various body areas and absorbed across the skin. Absorption of T by this method varies greatly between individuals. Children and pregnant women should not be exposed to testosterone, so care must be taken to avoid direct contact with the creams or gels. Brand name topicals can be very expensive, whereas compounded products are affordable. The biggest problem that I see with cream/gel topical T is that men function best with blood T levels that are 10 times higher than women. It is often difficult for men to absorb enough T topically to actually raise their levels. If you are placed on topical T therapy, make sure the doctor repeats your T levels to see how you have responded to the treatment.
Pellets are bio-identical T that are placed just under the skin in the fatty area of the buttock. Pellets slowly dissolve away to nothing, so they do not have to be removed. As T pellets slowly dissolve, they release testosterone in a continuous fashion “24/7″ achieving steady levels of T day and night (clearly this is desirable). The pellets last an average of 3 to 6 months (average of 4 months). The pellet dose should be based upon body weight. The heavier a man or woman is, the higher the dose of pellets. Dosing of T pellets in women range from 50-125mg, whereas men do best with over 1,000mg per treatment. Pellets are produced in different strengths, so the number of pellets placed during a procedure will also depend on the pharmacy that produces them. Patients with pellets enjoy the fact they do not have to fuss with topical creams or gels, and avoid painful injections every 2 weeks. For all these reasons, I only prescribe testosterone in a pellet form.
How do I select a provider for T Pellets?
Ask the following questions: Who inserts the pellets, what is their degree and how were they trained? Do they follow sterile procedures including use of sterile gloves, drapes and skin preps? I have found that many providers do not take care with sterile technique with the result that infection of the area may occur.
What is the Cost of T Pellet therapy?
This will vary greatly between offices and different states. Many offices that perform T Pellet therapy are doing so under a licensing agreement with a national company such as Bio-T, SottoPelle, HRC or Midwest Restorative Health. These offices are obligated to charge a higher fee as part of their agreement. At Omaha Med Spa I order my own pellets from a local compounding pharmacy, and run my own protocols and program. The result is that my T pellet therapy is affordable. The cost of T pellet therapy is generally not covered by insurance companies.
I want to have more children. Is testosterone safe for me?
When men are given testosterone therapy their sperm count and fertility will drop. In general, when they stop T therapy their counts and fertility should rebound, but there is no guarantee of that. If you are a man and you feel quite certain that you want to father more children, I suggest you defer your treatment until you are done having your family.
Women must use a reliable form of contraception while they are on testosterone therapy. If you become pregnant while on T, your baby may be at risk.
Carter Abbott MD