Most men find that their sexual desire increases after they start testosterone replacement. Sexual dreams and nighttime/morning erections may be more easily achievable, but in some cases testosterone alone does not make erections strong or lasting enough for successful intercourse.
For these men the use of prescription phosphodiesterase type 5 inhibitor (PD-5) medications like Viagra, Cialis, and Levitra - may be needed in combination with testosterone replacement. However, some men do not respond well to these oral agents or have side effects such as headaches, nasal congestion, flushing, gut problems, and, in the case of Cialis, back pain. Cialis may last longer than the others (36 hours compared to 4 hours for Viagra or Levitra), but so may its side effects. Some men take ibuprofen with these drugs to pre-treat nasal congestion and headaches, respectively. Cialis is also approved for daily use at 5 or 10 mg/day dose (regular dose is 20 mg/day). They are available by prescription but I have heard that some men are ordering them without a prescription from overseas websites to save money (overseas sources can be ten times cheaper than products in the United States). This book does not endorse the use of these drugs without a prescription, but it is my duty to mention facts about what is happening out in the real world.
Other options for men who need an extra erectile boost while using testosterone replacement:
Yohimbine - increases sex organ sensitivity. It can raise blood pressure and cause insomnia and anxiety, so talk to your doctor. A small study showed that men who used yohimbine with the amino acid arginine had better erections
Penile restriction rings—These rubber or leather restricting bands (commonly known as “cock rings”) can be very effective at maintaining erections after the penis fills up with blood. Be careful not to use it too tight. Neoprene and leather rings are the most common. They can be found online.
Other options are penile vacuum devices and penile implants. Due to the scope of this book, these two options will not be reviewed. Plenty of information can be found by Googling those terms.
Medications that could cause decreased sex drive or erectile dysfunction:
Medications can cause erectile dysfunction in some men. A great review of all studies of drugs that affect sexual function in men was provided by Dr Walter K.H. Krause. He was able to identify evidence from different studies (many uncontrolled and small) about the common classes of prescription medications that can cause erectile dysfunction. It is not known if testosterone replacement can counteract the effects of these medication classes.
Among the medications are:
- Antidepressants: Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors
- Blood pressure medications (antihypertensives): Alpha andregenergic antagonists, beta-blockers, diuretics, guanethidine, methyldopa
- Narcotics and opiates
- Barbiturates and benzodiazepines
- Hormone related products: anabolic steroids, antiandrogens used in prostate cancer, estrogens, medroxyprogesterone, 5-alpha-reductase inhibitors
- Anti-acids: Histamine 2 receptor antagonists, proton pump inhibitors
- Cholesterol –lowering agents: Bile acid sequestrants, fenofibrates, statins
If no improvements in fatigue are observed after 6 weeks of testosterone replacement, factors beyond hypogonadism may be present. Thyroid and adrenal function should be checked to ensure that those two glands are working properly Sleep apnea can also be a factor involved in the failure to improve stamina. Depression may still need to be addressed with the proper medications and counseling.
The thyroid is a butterfly-shaped endocrine gland located in the lower front of the neck. It produces thyroxine or T4, which is converted to tririodothyronine, or T3. T4 production is controlled by thyroid stimulating hormone or TSH, a hormone produced by the pituitary. Hypothyroidism, or low thyroid hormone, can cause sexual dysfunction as well as depression, fatigue, dry skin and hair, weight gain and increased sensitivity to the cold. Blood tests to measure TSH, T4 and T3 are readily available and widely used.
The adrenal glands, located in the abdomen above the kidneys, regulate stress in the human body. When the body encounters an emergency situation, the adrenal glands release hormones, such as adrenaline, that enable the body to respond accordingly. You may have encountered this reaction, called the “fight or flight” response, if you have encountered danger, fear or shock. Adrenal fatigue is the controversial idea that the adrenal glands can become worn out, creating illness, if continually over stimulated. Proponents of the “adrenal fatigue” theory hold that the adrenal glands may be over worked in some individuals and therefore become “fatigued” and unable to produce sufficient hormones. When your adrenal glands become exhausted, your natural cortisol levels drop significantly. Cortisol is your naturally occurring stress hormone. In addition to low sex drive and infertility, symptoms of adrenal fatigue may include chronic fatigue, low blood pressure and low blood sugar, dizziness, headaches, anxiety or panic attacks, depression,and other equally debilitating reactions. Some doctors may prescribe low doses of corticoid steroids if your morning levels of cortisol (measure by blood, saliva or urine tests) are low. But be careful with corticoid steroids since they can increase fat mass and decrease bone density if given in doses that exceed what the healthy adrenals would produce.
The adrenal glands also produce dihydroepiandrosterone (DHEA), the most abundant hormone found in the blood stream. The body uses DHEA as the starting material for producing the sex hormones testosterone and estrogen in men. Studies have shown that it only increases testosterone in women. The production of DHEA diminishes in most people after age 40. In people aged 70 years, DHEA levels will be approximately 30 percent lower than what they were at age 25. Low blood levels of DHEA have been associated with many degenerative conditions. Some controversial and non-conclusive studies have shown that people with immune deficiencies and fatigue may benefit from supplementation with this hormone. It is still available over-the-counter in the United States. This may change soon due to a new bill passed by Congress that classifies it as a performance-enhancing steroid (no studies have shown that it has such effect). One study showed that women with the correct levels of DHEA can convert it into testosterone as their body needs while men do not benefit to the same degree. You need a blood test to know if you have low DHEA-S since most of the DHEA converts into this sulfated form. Common doses for women are 5to 30 mg a day, while men tend to benefit from 25-100 mg per day (to bring low levels of DHEA-S to normal) All the hormones mentioned can be tested with blood tests or by using the easy-do-it-at-home mail order saliva hormone tests that are permissible without a prescription.
Sleep apnea is a sleep disorder in which the patient briefly stops breathing or breathes shallowly many times during sleep and therefore does not get enough restful sleep; oxygen levels drop in the blood, starving the brain of oxygen. In addition to causing daytime fatigue, it can increase blood pressure and cardiovascular risks. Testosterone-replacement therapy has been associated with exacerbationof sleep apnea or with the development of sleep apnea,generally in men who use higher doses of testosterone orwho have other identifiable risk factors for sleep apnea (high body weight, thick necks, snoring, alcohol consumption, and others). Upper-airwaynarrowing does not seem to be caused by testosterone replacement therapy,suggesting that testosterone replacement contributes to sleep-disordered breathing by central mechanisms rather than by means of anatomicalchanges in the airway. If your spouse or partner complains that you snore loudly at night and you suffer from fatigue, tell your doctor. The only real way to find out if you have sleep apnea is to have your doctor refer you to a sleep lab for a sleep study. If you are diagnosed with sleep apnea, a Continuous Pressure Airway Pressure (CPAP) machine can be prescribed to help you open up your airways with a small air pump while you sleep. Some people love it while some hate wearing a mask while being hooked up to a machine at night.
PERSONAL COMMENTS: Because of terrible bouts with fatigue in the past, I was referred to a sleep lab and diagnosed with mild sleep apnea. I tried CPAP with different masks (they are smaller ones with “nose pillows” and many other designs, so don’t give up early without trying different styles). I could not get used to it. I have had my thyroid and adrenal functions checked without finding any problems.Unfortunately I get anxious if I use them for long periods, so I only use them as needed. What has made the most difference, besides keeping my testosterone in the upper side of the normal range, is going to bed around the same time at night and waking up also at the same time. Traveling and other factors can interfere with maintaining a normal sleep cycle, but the fact is I need to listen to my body’s needs. I can usually be tired enough to get better sleep by the time bedtime arrives if I avoid caffeine after 3 pm and don’t exercise too late at night.