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Low Testosterone? Separating medical advice from marketing with Dr. Andrew Smith

            “Hey Doc, do you think I have low T?”  It’s a question that comes up quite a lot these days.  Whereas 10 or 15 years ago, testosterone (T) was an occasional level to be checked, it is now a frequent part of a blood workup.  This may be partly due to marketing.  But, at the same time, low T is rather common, affecting perhaps 20% of men or more.  That estimate keeps changing, partly because what is considered a normal T level keeps being changed as well.

Clinical low T is diagnosed when a low blood of testosterone is coupled with some of the signs or symptoms of low T.  So, what are these signs and symptoms?  They can include anemia, muscle wasting, reduced bone density, increased belly fat, sexual dysfunction, reduced sense of vitality, depressed mood, decreased motivation, increased irritability, difficulty concentrating, and/or hot flushes. Of course the problem is that these symptoms can have many other causes as well.  Still, they are troublesome enough that a T level is worth checking if someone has some of them.

It is probably not a good idea to simply screen all men for low T and treat everyone whose number is low.  Why?  If someone isn’t having any of the symptoms of low T, it isn’t generally recommended that they be treated with T replacement.  T replacement can occasionally have side effects.   For example, if you have the beginnings of prostate cancer, T may stimulate it to grow more rapidly, though it doesn’t seem to increase the incidence of prostate cancer.  T can also worsen benign enlargement of the prostate leading to increased difficulty with urination.  Fluid retention and an increase in red blood cell count can also occur and thereby increase blood pressure, heart failure, heart attack and stroke in those who are prone.  The numbers here don’t seem to be large, and there are some definite benefits to T replacement, but the point is that only those who will truly benefit should be treated with T replacement.

Perhaps surprisingly, sperm production can also be reduced by T replacement, thus impairing fertility.  Sometimes the sperm count doesn’t readily return to normal after T replacement is stopped.  So, for young men who may wish to have more children in the future, rather than directly giving T, there are other prescriptions such as clomiphene that can stimulate the body’s own T production without impairing the sperm count.

All those precautions being noted, if you have some of the symptoms of low T which we have listed, it makes sense to check a T level.  If indeed your levels are low, and you have symptoms that correlate, it is certainly reasonable to consider a trial of testosterone replacement.

What are your choices for replacement?  Testosterone is not absorbed well when swallowed.  So, T can be given by injections, patches, gels and dissolvable oral pellets given by prescription.  Levels can then be rechecked to ensure that adequate replacement has been given.  The other key is to see whether the symptoms of low testosterone have actually improved substantially with replacement.  T replacement is only continued if it actually helps your symptoms and doesn’t give troublesome side effects.  Usually a 2-3 month trial is long enough for a man to know how much difference T replacement makes in how he feels.  We have many men in our practice who find that T replacement has greatly improved their sense of well-being and who have no interest in going back to being without it.

This whole issue of when low testosterone is really pathologic, when it should be replaced, and for how long, is still an evolving story but more and more practical answers are being hammered out. So, if you’ve got the symptoms, get it checked, and then think it through with your doctor and decide whether to treat your low T and how.

 

Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835

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Thankful for Our Bodies

Thankful for Our Bodies

Some sixteen centuries ago, Augustine observed, “People travel to wonder at the height of mountains, at the huge waves of the sea, at the long courses of rivers, at the vast compass of the ocean, at the circular motion of the stars; and they pass by themselves without wondering… Now, let us acknowledge the wonder of our physical incarnation- that we are here, in these particular bodies, at this particular time, in these particular circumstances.”  It’s a good reminder as we approach Thanksgiving.  Let’s take a moment to wonder.

It’s a natural tendency we have to notice what’s not working right in our bodies rather than to give thanks for the huge number of processes that are working wondrously well.  Consider a few wonders of the bodies our Creator has given us: There are a trillion nerves powering our memory. These can send and receive messages at up to 200 miles per hour.  A study showed that after viewing 2,500 images for 3 seconds people can recall if they’ve seen the images with 92% accuracy.  Speaking of viewing, our eyes can distinguish nearly 10 million shades of color.  Those eyes are protected by the fastest muscles in the body, those that cause us to blink, in about a hundredth of a second.  And even more staggering than the eyes’ color discernment is the less glorious nose that can differentiate between 1 trillion smells.

            Of course all our cells and tissues need nutrition and oxygen delivered to them.  This occurs as blood travels through our blood vessels, which if laid end to end would stretch nearly 100,000 miles.  The heart makes this happen by pumping about 100,000 times per day.  This then adds up to about 3 million quarts of blood pumped by your heart every year.   

            How does the blood keep picking up a new load of oxygen and getting rid of the waste gas carbon dioxide?  You take about 23,000 breaths a day, or about 672,768,000 breaths in a lifetime, usually without even thinking about it.  And the oxygen and carbon dioxide are diffused over the surface area of the lungs, which if it were flattened out would be equal to the surface area of a tennis court.

            And talk about strength, the femur (upper leg bone) of an average-sized man can withstand 30 times our weight – ounce-for-ounce that is stronger than steel.

            Even some of the lowliest bodily functions are impressive.  For example, the average human produces 25,000 quarts of saliva in a lifetime, enough to fill two swimming pools; try swallowing or speaking normally without saliva.

            So, how did we get the information for the construction process of our beyond-ingenious bodies?  It’s encoded in our DNA which, if uncoiled, would stretch 10 billion miles.  And its encoding of information is so efficient that just one tiny DNA molecule contains 40 times the information in a set of Encyclopedia Britannica. 

It’s a rough world out there, and it wears on our body.  Fortunately, much of the human body is self-regenerating.  For example, the stomach lining is replaced every 4-5 days so that it doesn’t digest itself, since stomach acid can dissolve metal.  Meanwhile, skin is replaced about every 2-4 weeks and our bones are fully replaced about every 10 years.  In fact, 50,000 cells in your body died and were replaced by new ones while you were reading this sentence.

We could go on, but hopefully you get the idea, and it’s not a new one – some three thousand years ago, King David wrote (in Psalm 139) to his Creator, “I praise you, for I am fearfully and wonderfully made. Wonderful are your works; my soul knows it very well.”

Since among so many other gifts, we have been given the ability to remember, let’s remember on this Thanksgiving to give thanks to our Creator for the truly amazing bodies He has given us.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835

 

 

           

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Polymyalgia Rheumatica

             “Wow, I guess I’m just getting old.  Everything hurts and I’m tired even doing little things.” Mrs. Jennings, in her early sixties, was normally one of my more energetic patients.  On further questioning it turned out it really wasn’t “everything” that hurt, but particularly the muscles of her thighs and shoulders, not so much her joints.  Her tiredness was notable particularly when she would exert herself, like walking up her back hill.  She would get back into her house from coming up the hill and feel totally out of breath, achy and exhausted.  All this was a rather striking change from just a couple weeks ago when none of this gave her much trouble at all.

dementia.stock.photo.site            Was she right that age had finally caught up with her?  Or maybe she had some hidden cancer, or late-onset rheumatologic disease, or any number of other problems.  Most of the tests came back pretty normal, but an old, simple blood test, the sedimentation rate, was very high.  It’s a non-specific test, but together with her other symptoms and the normalcy of most of the rest of her tests, it pointed to a diagnosis we see only occasionally: polymyalgia rheumatica (PMR).  The clincher would be how she responded to a course of oral steroids.  They tend to work like magic with PMR and that helps confirm the diagnosis.  Sure enough, a week or so after starting the steroids, we had the younger, energetic version of Mrs. Jennings back.  She was again motoring up her back hill like it was nothing.

As with Mrs. Jennings’ episode, PMR involves the rapid onset of soreness in the large muscles of the thigh and shoulders with a sense of weakness and fatigue.  Sufferers are almost always over age 50 and more than twice as many women as men get it.  The cause is not known and is thought to possibly be autoimmune.  As noted, steroids work wonders for PMR and can then be slowly tapered over many months.  The entire course of PMR averages about three years.  It’s one of those diagnoses you don’t want to miss since it’s so debilitating to have, but so very treatable.

Importantly, about 15% of people with PMR also have a condition called giant cell arteritis (GCA), which has also been called temporal arteritis.  GCA involves inflammation of arteries, most commonly the temporal arteries on either side of the forehead.  GCA causes a substantial temporal headache, and if untreated (with higher dose steroids), can even cause sudden blindness.  Mrs. Jennings actually had some temporal pain that came and went.  In the end we had her get a temporal artery biopsy but happily it was normal.

It is always very satisfying, to doctor and patient alike, to see the debilitating fatigue, weakness and achiness of PMT quickly melt away with treatment.  And unlike almost 50% of individuals with PMR, Mrs. Jennings did not experience a relapse.  Several years later, she’s still going strong, motoring up her back hill like its nothing.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835

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The Black Dog of Depression

            “I am the most miserable man living.  If what I feel were equally distributed to the whole human family there would not be one cheerful face on the earth.  Whether I shall ever be better, I cannot tell.  I awfully forebode I shall not.  To remain as I am is impossible.  I must die or be better.”  That quote is by none other than Abraham Lincoln.  Likewise, Winston Churchill referred to his depression as his “black dog.”  Most depressed patients aren’t quite so striking in their descriptions.  They may complain of a loss of interest in things that used to seem important to them, or a general fatigue, or frequent tearfulness, or just a persistent irritability.

Depression may be the 3rd most common psychiatric disorder behind anxiety and phobias, with approximately 15 million Americans experiencing a depression each year. So, since we can all have some bad days or a period of sadness, what, from a medical perspective, defines an actual depression?  According to the most common psychiatric definition, as contained in something called DSM 5, a major depression involves: A depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period.   Overall functioning must also be impaired by the change in mood.  In addition, at least 5 of the following symptoms must be present:

  • Depressed mood
  • Decreased interest or pleasure
  • Weight change of 5% or more (up or down)
  • Sleep disturbance
  • Psychomotor agitation or retardation – consistently slowed movements or agitated movements
  • Fatigue
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death and/or suicide

As you read through that list, some of you may be seeing a description of yourself or someone you love.  Before we take a moment to look at what can be done about it, let’s first ask how does someone get here – what causes someone to get depressed?  That can be a complicated question as depression is often the result of any combination of several factors.  Everything from genetics to circumstances and how we think about those circumstances can play a role.  Sometimes chronic stress and anxiety or even physical illness or loss can trigger a depression.

The wide range of causes of depression plays into the several kinds of treatment that are employed.  Primary care doctors are sometimes called the psychiatrists of the masses since the majority of depression treated medically is carried out in primary care offices.  When seeing your primary care physician for possible depression, a number of physical contributors such as hypothyroidism , low testosterone, or medication side effects can be ruled in or out.

If these physical causes are not a significant factor and a major depression is diagnosed, several treatments can be considered.  Starting with simple approaches, regular exercise such as a brisk walk has been shown in studies to sometimes help as much as a prescription antidepressant.  Likewise, informal counsel with any mature friends or family can be helpful.  Pastoral counsel from a trusted pastor is often a further aid in working through a depression.

Beyond these helps, specific medical interventions can be considered.  Formal counsel can often provide further tools to battle depression.  Finally, prescription meds can have their place as well.  These are far from 100% effective and it can sometimes take time to find the one that is most effective for a given individual, but at times they can be enormously helpful.

Depression, as Lincoln said, can be absolutely miserable, both for the individual, and for those around them.  Ideally, it should be responded to as aggressively and directly as a heart attack, since in its own way it can be just as devastating.  So if you suspect the black dog of depression is sinking its teeth into you, get it checked out.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835

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