Para/Medic: SCI and Low Testosterone Levels


bob-vogelBIOpic


Q.
I’m 58 years old and in my 20th year as a T7 complete paraplegic. Over the past few years it seems I’m always tired, have difficulty focusing on tasks and have lost enthusiasm for going out and doing my usual sports of handcycling and swimming. It is a struggle to get out the door and do them.

I’ve read that people with SCI have a higher incidence of low testosterone and that testosterone replacement can help improve energy, muscle mass, and concentration. Have you heard of this? And if so, how do I find out about it?
— Scott

A. Scott, you bring up a good question — a Web search of “chronic spinal cord injury and low testosterone” brings up page after page of articles and studies that conclude that low testosterone occurs in a higher percentage of men with SCI than the general public.

According to the Mayo Clinic (2015 online), in the general population testosterone levels peak in adolescence or early adulthood, then decline about 1 percent per year after 30 or 40. However, a study published in a 2014 issue of the Journal of Spinal Cord Medicine states: “Persons with SCI appear to have a higher prevalence of low T concentration for each decade of life than those in the general population and … the low T values tend to occur earlier in life in persons with SCI. The decline in serum total T concentration over time in the group with SCI was 50 percent greater than that for the nondisabled controls.” Also, an October 2011 study in Physical Medicine and Rehabilitation concluded that low testosterone levels were significantly associated with motor complete (ASIA A and B) injuries and much less with incomplete (ASIA C, D, and E) injuries and suggests that a testosterone level test should be included in standard screenings for people with complete SCI.

“We screen men for low testosterone if a man has low energy or low libido,” says Paula Wagner, a urology nurse practitioner at U.C. Davis Medical Center in Sacramento, Calif. Wagner explains that the range of what is normal is very wide, and if your results fall within the normal range, you do not need testosterone replacement. Testosterone levels are checked via blood test and should be done before 10 a.m., since levels tend to drop off in the afternoon. Lower testosterone production or metabolism can be caused by stress, excess exercise, and certain medications, including opiates.

Signs and symptoms of low testosterone include fatigue, low sex drive, depression, inability to concentrate, reduced muscle mass and strength, increase in central body fat, and decreased bone density. Stanley Ducharme, professor of rehabilitation medicine and assistant professor of urology at Boston University School of Medicine, discusses decreased bone density in his article “Testosterone and Spinal Cord Injury.” He says scientists are questioning whether osteoporosis in people with SCI may be related to lower testosterone levels, along with lack of weight bearing and other SCI factors.

Wagner says before taking testosterone replacement therapy, it is important to have a discussion with your physician and weigh the risks and benefits. Potential benefits of replacement therapy include enhanced energy and mood, increase in libido, increased muscle mass and strength, and decrease in body fat. Some of the risks include increased red blood cell counts (which also increases the risk of blood clots); causation or worsening of sleep apnea; and stimulating growth of prostate cancer. Men with an elevated prostate-specific-antigen test level should avoid replacement therapy — it may increase prostate size or worsen benign prostatic hypertrophy (enlarged prostate).

The key with replacement therapy is to take the correct amount of replacement to keep testosterone within the normal range, says Wagner. “It is important to have a doctor who can look at your lab values and say, ‘based on age, your levels should be X,’” she says. “If your levels are in the normal range and you add testosterone, you add a lot of health risk for no real benefit.” It is never OK to try testosterone replacement on your own. Personally deciding to try testosterone therapy or guessing at how much to use without consulting your doctor amounts to an extreme health risk, and could even result in death.

If your testosterone level is low and you and your doctor decide replacement is the way to go, there are several options, including transdermal patches, gels, mouth patches, injections, or implanted pellets. Wagner says it is important to be monitored so your levels don’t get too high. This means having a blood test every three to six months.

Mike Trijillo, 68, from Huntington Beach, Calif., is in his 49th year as a T5 ASIA B, motor complete para. At 60, when he was a renowned wheelchair racer, Trijillo was in top physical shape but was becoming increasingly fatigued. He discussed this with his doctor, who ordered a blood test to get testosterone levels. The test showed his level was below normal. After discussing the pros and cons of replacement therapy, his doctor prescribed testosterone cream. “It was great, it raised my energy level and raised my sex drive, and it enabled me to do exercise workouts like a madman,” he says.

Replacement therapy worked great for about six years and then Trijillo started gaining weight around his middle, which testosterone replacement is supposed to reverse, so Trijillo stopped using testosterone cream a year and a half ago — the risks now outweighed the diminishing benefits. He is giving his body an extended break and may decide to talk with his doctor about resuming treatment at some point in the future. “I plan to get another 20 years on this planet, and with SCI it seems we are always adjusting or dealing with some health issue,” he says.

Recreational activity, exercise and proper body weight may play a role in testosterone levels. A study in the September 2014 issue of Andrology explains that there has not been an established cause for higher rates of testosterone deficiency in men with SCI. The study found a significant correlation in men with SCI who have low testosterone levels and who participated in fewer weekly leisure time activities and had an increase in body mass index. Which raises the question, which came first, low testosterone leading to inactivity and weight gain, or was it the other way around?

The study suggests a follow-up study involving life-style modification. The hypothesis is if you have symptoms of low testosterone and aren’t participating in leisure activities and are overweight, by modifying your lifestyle to lose weight and make time for leisure activities that involve exercise, you may naturally increase testosterone levels, improve energy levels and sex drive. If nothing else, trying this will help you feel better, an experiment that can be done on your own at low or no cost and put you one step ahead of researchers.

Resources
• Andrology, www.ncbi.nlm.nih.gov/pubmed/24925765
• Testosterone and Spinal Cord Injury, www.stanleyducharme.com/resources/testosterone-injury.htm
• Journal of Spinal Cord Medicine, www.ncbi.nlm.nih.gov/pubmed/24090163
• Physical Medicine and Rehabilitation, www.ncbi.nlm.nih.gov/pubmed/22024324


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