What is Low Testosterone / Andropause?
Maybe your sex drive is low. Maybe your energy level, strength or muscle mass aren’t up to par. Maybe your erections aren’t what they used to be. These symptoms may all be linked to a drop in hormone production which means that you should probably be evaluated for Low Testosterone.
If you feel you’re too young to have Low T, you should know that many men as young as 30 suffer from Low T.
If you think you’re too old to benefit from TRT, you should know that many men are treated very successfully until well into their eighties.
If you have been treated for Low T but not seen the results you’d hoped for, you should know that the best results will only be achieved by a specialist.Because Low T is a complicated condition that presents differently in different men. Just checking your testosterone level will be of limited use unless someone has the expertise to understand it within the context of your overall health. And a treatment plan can’t be optimized unless a specialist continually monitors and calibrates it to achieve the best possible results.
If you are interested in getting treated for Low T but are concerned about potential risks that you’ve seen covered in the media, you should speak to a specialist who can help you understand the research that clearly shows there is no increased risk of prostate cancer or cardiovascular disease associated with TRT.
Low Testosterone (Low T), or Andropause, describes an emotional and physical change that many men experience as they age. Although the symptoms are generally related to aging, they are also associated with significant hormonal alterations. While medical professionals have known for a long time that the production of hormones by the testes slowly decreases as men age, interest in the clinical implications of that decrease has only developed recently.
Andropause is also referred to as male menopause, male climacteric andropause, male andropause, late onset hypogonadism, or androgen decline in the aging male (ADAM).
The good news is that therapy is often very effective. The goals are to restore sexual functioning, increase libido and sense of well-being, prevent osteoporosis by optimizing bone density, restore muscle strength and improve mental functions. Our aim is to bring your levels of serum testosterone back to “high normal” levels. Beyond this, we aim to normalize other hormones that may be abnormal as well. These include, thyroid hormone, DHEA, estradiol (the main female hormone), and prolactin.
There are a number of ways to treat this condition including transdermal (through the skin) patches and gels, injections, and long-acting slow release pellets. Each modality has its own advantages and disadvantages. Factors include: ability to get good levels, transmissibility to others, frequency and ease of use, and personal preference.
It is important to note that testosterone is not available orally. This is because all drugs absorbed in the stomach go to the liver first. The liver thus gets a very high concentration of the medication. In the case of testosterone, this can increase the chance of liver disease and cancer. This is not the case when it is given by other modalities.
Topical Therapy/Applied to Skin or Mucous Membranes
Testosterone can be applied to the skin or to mucous membranes (the inside of the nose or mouth.) Mixed with the testosterone are specific ingredients that help get it into the bloodstream, and then to the rest of your body. Most often, this is the “first line” therapy. The range of options and number of branded and generic preparations continues to grow.
The testosterone may be applied to the:
- Inside lining of the cheek (buccal mucosa)
- Inside of the nose (nasal mucosa)
- As a skin patch
- As a skin gel (including the back, chest, shoulders, arms, and thighs)
- As a topical solution placed in the axilla (armpit)
Most men start with the topical medications, as they are less intimidating. If for some reason, a man doesn’t like it, he just doesn’t have to do it the next day.
However, to be effective, all of the topicals must be placed every day. For some men, this is a non-issue. For others this is a burden. They may not be able to remember to put it on consistently. They may not like the way it feels, smells, or tastes.
Many men get good absorption and are able to attain good blood testosterone levels. However, a significant number of men are not able to absorb the medication, and never get good levels.
We always check levels, and switch to a different modality of testosterone replacement, if blood levels are not good enough. In general, we find that if a man is not getting good absorption with one gel or solution, he will not get good levels with a different one. Typically, we will switch to a totally different method.
Since the medications take some time to be absorbed, it is important not to remove them until they have had adequate time to be absorbed.
For the gels and solutions, this is a minimum of two hours. Thus, the user should not shower, swim, or work-out until at least two hours after they have been applied.
For the intranasal (up the nose) gel, which is used three times daily, it is important not to sniff or blow your nose for an hour after use.
Though the gels and solutions take a minimum of two hours to be absorbed, they are not completely absorbed at this time. Thus, it is important to shower prior to having skin to skin contact (particularly with women and/or children) to the area where the medication was applied. To avoid transmissibility, you can simply put on a T-shirt.
We usually have our patients apply their once daily medications at night, then sleep with a T-shirt, and shower in the morning, so they are finished with the application for the day.
Most men with pregnant wives or children are not particularly comfortable with using the gels or solutions. There should be no transmissibility issue with the patch or the nasal gel.
Since the medication is placed on a particular surface (skin or mucosa) it may cause local irritation.
Local irritation seems to be most common with the patch, where our experience shows that almost no men can tolerate it. Men who are very motivated to use the patch can put a thin layer of hydrocortisone cream over the area first. This often cuts down on the irritation, without decreasing absorption.
For the topical gels and solutions, many men develop rashes or burning. This may be true, even if they rotate the site of application. However, many men have no skin issues whatsoever.
Testosterone may be injected into the layer of fat underneath the skin (subcutaneously) or into the muscle (intramuscularly- IM), usually the thigh, arm, or buttock. This method has been used by physicians for years, and predates the use of topical testosterone by decades. ( It is also the method that has been most abused by bodybuilders and athletes.)
Traditionally, testosterone was injected only intramuscularly. However, experts have recognized that it is also equally well absorbed when injected into the fat underneath the skin. The needle is much shorter this way, and most men report preferring this technique.
There are various formulations of injectable testosterone. The most common are testosterone cypionate and testosterone enanthate. Testosterone cypionate is the one that virtually all physicians, including us, prescribe.
The dosage is dependent on the individual. In general, we are aiming for men to feel better, which usually correlates to being in the” high normal” range. We have men injecting as low as 100 mg weekly, and as high as 220 mg weekly. We follow both symptoms and blood work.
Some men notice the ups and downs correlated to the variable levels during the week. These men are then counseled to split the dosage into two, and give themselves two injections per week. This often avoids the peaks and valleys experienced if the medication is given only once during the week.
Many physicians require their patients to come into the office weekly for their injections. This is, of course, burden for many patients. In fact, most patients cannot follow through and drop out of treatment. Other physicians, using the same rationale, give their patients a large dosage on a biweekly or monthly basis. However, this makes the patients have huge peaks and valleys based on how much is in their system. It also results in more side effects.
The rationale for requiring the patient to come into the office is that this is a restricted drug, and could be abused by the patient. This makes no sense to us for several reasons. The prescribing practitioner knows how much s/he is prescribing. If the patient is running through it much faster than he should be, then there is a problem which is immediately apparent. Also, if a patient wants to abuse steroids, he can just obtain them illegally at many gyms, and doesn’t need the physician in the first place. By putting a reasonable and doable treatment plan in place, we feel it is more likely that patients will follow a safe medical regimen.
How is Injectable Testosterone Supplied and How Much Does It Cost?
Testosterone cypionate comes in 10cc and 1cc vials. We strongly recommend our patients get the 10cc vials, as the liquid is very thick (viscous) and it is quite hard to empty the 1cc vials. It is usually more expensive, per cc, to purchase 10 vials of 1cc than it is to purchase 1 vial of 10cc’s.
It is available at almost all pharmacies, but sometimes needs to be ordered in advance.
Many drug plans will only pay for one month of medication at a time, which means they will not release a 10cc vial. Fortunately, the medication is relatively inexpensive, and sometimes it is even cheaper to purchase the 10cc vial without using your prescription plan than it is to pay a monthly co-pay and get the 1cc vials. Using a website like goodrx.com or rebates.com, you can make the pharmacies compete for a reasonable price, and a 10cc vial should cost between $35 and $55 (without using your prescription plan).
Thus, for patients without insurance, or with poor drug coverage, the injectable testosterone is by far the cheapest option.
Advantages of injectable testosterone
- Lowest Cost
- Weekly or Biweekly injection (rather than daily application for topicals)
- Dosing: unlike the topicals, the injectable testosterone is always absorbed; we can always get men good levels using this modality.
Disadvantages of injectable testosterone
Testosterone cypionate is the oil-soluble 17 (beta)- cyclopentylpropionate ester of the androgenic hormone testosterone. In other words, it is not bio-identical testosterone. Men have been making their own testosterone since before we evolved into homo sapiens. But, we have not been making testosterone cypionate. Thus ,there may be some long term side effects of testosterone cypionate that we are not aware of. (Testosterone pellets are an excellent alternative that are bio-identical.)
There do seem to be more side effects from testosterone cypionate than from bio-identical testosterone. These include more acne and more increases in hematocrit and estrogen. It is unclear whether this is because there are more peaks and valleys in weekly or biweekly doses than with daily application treatments.
>Self-Injections can be Uncomfortable
Testosterone cypionate is a very thick (viscous) liquid. It is slightly difficult to draw up, and somewhat uncomfortable to inject.
Men do have to remember to give themselves an injection every week, or twice weekly. For some men this is simply not feasible, either because they dread it, or they simply can’t remember.
Testosterone pellets can be inserted in the fat underneath the skin (subcutaneously) once every three months. This is done in the office, and takes less than ten minutes. It has become the most popular method in our practice.
The pellets each contain 75 mg of testosterone. Each pellet is approximately the size of a grain of rice.
In terms of dosing, we can always get good levels of testosterone which we can adjust simply by varying the number of pellets placed, all of which go through the same small skin incision.
How is it Done?
Most of the time, the pellets are placed through a small incision in the skin of the buttock. The incision is so small it is closed with a butterfly bandage (steri-strip). The location is chosen so that it is below the belt line, and above where you sit. No matter how many pellets are placed, only one small skin incision is made.
After the procedure, a butterfly dressing is put on the small nick to hold the edges together, and then a clean dressing. The dressing is waterproof so a man can take a shower with it on. The dressing can be removed after 48 hours. The butterfly dressings then fall off on their own.
We ask our patients to compress the site and apply ice for a total of 15 minutes, directly after the procedure to limit swelling and bleeding.
Men love the fact that they only need to think about this once every three months. Once we have determined the correct dosage, they only need to come to the office once every three months.
Unlike the topicals, we can always get men good levels with the pellets.
The testosterone pellets are bio-identical. This means that they are exactly what your body makes. Thus, any side effects would only be due to the dosing not to the actual medication itself. In our practice we have a strong preference for bio-identical hormones for this exact reason.
Most insurance companies pay for this medication and for the procedure. (However, if they do not, it is much more costly than the testosterone injections.)
Some men do not like the procedure. Either they are intimidated by the procedure itself, or they have some post-procedure swelling, bruising, and/or discomfort.
Slightly less than 1% of the time, the site can have a small infection. Almost invariably the man’s body responds by opening up the tract that the pellets went through and “spitting” them out. We have never had an abscess or needed to drain the area. We have not needed to give systemic antibiotics.
As discussed in detail in the previous section, there isn’t one “right” level of testosterone that all men require in order to maintain proper function of their brain, bones, prostate, penis or muscles.
There are some physicians who say that decreased testosterone is a natural part of aging and that no treatment is warranted. We couldn’t disagree more! In general, medicine aims to improve the quality of our lives through prevention and treatment. This is why we replace joints that have worn out by natural aging and use. We also prescribe glasses and remove cataracts. We treat high cholesterol, diabetes and hypertension, all of which worsen with age.
In our experience, and medical literature bears this out, the vast majority of men who are treated with TRT experience significant improvement in the way they feel– in terms of libido, erections, muscle mass, cognition, and energy levels.
We discuss the specific risks of TRT below. These risks are under active investigation, and, at least in the public discourse, remain controversial. However, when patients are carefully monitored and responsibly treated, these risks are minimal (if there are truly any at all.) In our minds, the known benefits from TRT vastly outweigh the theoretical risks.
Testosterone Levels Less Than 300 ng/dl With Symptoms Or Signs
If a man has symptoms and a testosterone level of below 300 on two separate occasions (and no contraindications), he is an excellent candidate for TRT.
Even if he is not reporting symptoms ( like low libido or energy levels), a low testosterone level leads us to evaluate for signs he may not be aware of, such as decreased bone density and diabetes or pre-diabetes.
Abnormal Bone Density
Decreased bone density makes a man more likely to have fractures and breaks. If the bone densitometry (which screens for decreased bone density) is markedly abnormal, we will institute TRT.
Pre-diabetes means that your average blood sugar (measured as hemoglobin A1c) is elevated, but you do not yet fit the criterion for diabetes. Most people in this category will progress to type 2 diabetes in less than 10 years if there is no intervention made. The most obvious interventions are diet and exercise modifications. However, there is mounting evidence that increased testosterone helps with glucose metabolism.
Certainly, increasing exercise has a significant impact on glucose levels. Men treated with testosterone will usually have increased energy to start exercising and continue exercising. They will also lose more fat and build up more muscle from the same amount of exercise.
In our practice. these men will also work with our exercise physiologist to direct, motivate, and monitor their progress. We have seen dramatic changes, in both the way men feel and in their blood sugars!
Testosterone Levels Less Than 300 ng/dl Without Symptoms Or Signs
An interesting issue arises when a man without symptoms, or with minimal symptoms, is found to have a low testosterone level. This is often found during an infertility evaluation, for example, and is certainly a controversial idea.
For these men, we will of course review the benefits and risk in depth, as we always do. However, the benefits may be more subtle, than for the men with significant symptoms or signs. A low testosterone is their baseline. They may feel well overall. Or, they may have compensated for their low testosterone by pushing through. They may not know what they are missing! In these situations, we will offer TRT.
In our experience, the vast majority of these men who decide to try TRT, as well as their partners, have noticed dramatic changes and remain with TRT.
Low-Normal Testosterone Levels With Symptoms And/Or Signs
However, what about men with significant symptoms and/or signs with testosterone levels in the 300’s and low 400’s? This remains a controversial area and we discuss, at length, the problems with what constitutes a “normal” testosterone in the previous section. In that section we ask the following question: Should a symptomatic 27 year old man with an average testosterone level, using morning readings of less than 425 be treated? We think yes, and our experience has borne this out.
Interestingly, it has been found that different symptoms respond to treatment at different rates.
“I Feel 18 Again!”
Some men will notice a dramatic improvement even in the first month or two of treatment. We enjoy hearing them say, “I feel like I’m 18 again!” but we are always careful to warn them that IT WILL NOT LAST!
What they are feeling represents a response to the dramatic change in testosterone; the “delta.” This will usually wear off after a few months, though they will still be feeling better over time than they felt originally. It is always important for us to compare how a man feels compared to his baseline, rather than this peak. Men who abuse steroids are often chasing this peak, and need to use higher and higher levels of steroids to achieve it. This is both dangerous and futile.
Increased Muscle Mass And Energy
Increased muscle mass and energy are typically the first things men receiving TRT notice. Usually, by four months of treatment these are apparent.
After four months, many men notice that they are no longer feel the need for a nap in the middle of the day. Their stamina levels, at work, at home and while exercising, improve significantly.
Most men will notice a significant change in lean body mass within 4 months. The average man will put on four pounds of muscle and take off four pounds of fat. Men who step up their exercise regimens will usually notice a much more dramatic difference.
Some men get tripped up on the fact that their weight may not decrease. However, if they build up more muscle while they take off fat, this may be the case, and represents the best of all possible worlds in terms of their health and their body image. A decreased waist size, for example, and increased arm, shoulder and chest, is a good outcome.
Many men will start noticing improved erectile function at about six months of treatment. Physiologically, it has been shown that increased testosterone levels increase the amount of muscle in the penis and decrease the amount of fat and fibrotic tissue.
For many men, one of the first physical responses they notice is an increase in the quantity and quality of their nocturnal or morning erections.
Some men, with very modest erectile dysfunction (ED) may find that their spontaneous erections become excellent again, and they no longer have ED or need oral medications to achieve an excellent erection.
However, it is important to remember that this does not mean that all men with ED will regain normal functioning. TRT should improve erections, but it does so only incrementally. For example, if you have very modest ED, occasionally needing low dosages of oral medication, you may find that you do not need the medication any more. If you have consistently needed oral medication, you may find you need it less frequently, or a lower dosage. If you have been using injections at a low dosage, you may find that the oral medications work sometimes.
It is vital to remember that men with significant ED, using high levels of injections to achieve a good erection, should not start TRT in the hopes of regaining spontaneous erections. This is highly unlikely. If this is their only symptom, then TRT may not be indicated.
In sum, improved erectile function is a nice benefit of TRT, but ED is usually not a stand alone symptom for which TRT is started.
Libido/Interest In Sex
As discussed, decreased libido is more common in men than is often thought. It usually has a devastating affect on both the man and his partner.
What libido is, why it diminishes, and how to treat it are complicated issues making it subtle and sometimes difficult to treat.
For unknown reasons, probably relating to brain chemistry, it may take a man nine months of good testosterone levels on TRT to notice a significant change in libido. This is often quite frustrating for the man and his partner. Thus, we make sure to discuss this delayed response at the beginning of treatment.
However, the vast majority of men will have an improvement in their libido with TRT, even if there are other psychological or relationship issues present, .
How Long Should I Stay On TRT?
Testosterone Replacement Therapy only works when you are on it. There is unfortunately no way of permanently “jump starting” your own production of testosterone. We are not “curing” the problem, we are managing it.
When starting TRT, we tell patients that in order to really know whether or not it is going to help them, they should commit to themselves to be managed for a year. In other words, they should not give up treatment until they have had excellent levels of a year. If after that time, they or the other people in their life (partner, family, friends, co-workers) have not noticed a significant difference, they should consider stopping treatment.
Can I Stop TRT?
There is definitely a small group of men who do not notice an improvement in their symptoms after a year of TRT. For these men, unless there are medical reasons to (i.e. decreased bone density) to continue treatment, TRT should be stopped. This always remains the patient’s decision.
Sometimes, men want to consider coming off TRT just to see how they feel without it. If TRT is stopped, the man’s levels will likely return to where he would have been if he had not begun treatment. However, his natural production will have decreased slightly, just as a product of aging. It is thought that some men will go back to slightly lower levels than they would have been, if they had not started treatment. The reason for this is unknown.
Sometimes when a man wants to consider coming off of TRT, it is the partner who insists he stay with treatment. When we go back and compare his pre-treatment to their post-treatment questionnaires, many men decide not to come off treatment. Other men notice a dramatic recurrence of their original symptoms and resume treatment.
Contrary to what you may have seen in the media, the preponderance of medical evidence clearly shows that treating Low T with TRT (Testosterone Replacement Therapy) does NOT increase your risk of prostate cancer or cardiovascular disease. In fact, studies correlate TRT with improved cardiovascular and overall health5.
The two issues that concern men and their partners about testosterone replacement therapy (TRT) are:
- What are its effects on the prostate? Will I have a higher chance of getting prostate cancer? Will my prostate get bigger and give me urination symptoms?
- What are the cardiovascular effects? Do I have a higher chance of having a heart attack, stroke, or blood clot with TRT?
Testosterone Effects on the Prostate
It is important to address this point in depth, because this fear is often what makes men decide not to begin TRT.
The overwhelming mass of evidence shows that:
Increasing Testosterone Levels does not increase a man’s chances of getting either Prostate Cancer or an Enlarged Prostate!
If this is the case, why is it of such concern to people? The answer to this question is complex but worth understanding.
We do know that men who have metastatic prostate cancer (it has spread to other organs) will have a slowing of their prostate cancer’s progression if their testosterone levels are brought to as close to zero as possible. It is therefore true, that if we brought every man to a zero testosterone level, we would have fewer men with prostate cancer. However, we would also have a lot of unhappy and otherwise unhealthy men. Clearly, no one would suggest that this be done to all men.
Because of this connection, the fear has been that if we give men testosterone, it will act as “fuel to the fire.” In other words, if there is any small amount of cancer in the prostate, giving a man extra testosterone will cause it to grow and spread.
However, there is significant data that this is not the case.
Men with higher natural testosterone levels do not have a higher incidence of prostate cancer, which they would if more testosterone causes prostate cancer to grow. In fact, there is significant data which shows that men with low levels of testosterone are at higher risk of developing prostate cancer. Why this is the case is not understood.
There is no evidence that men who are given testosterone have a jump in their PSA’s. (An increased PSA would be evidence either of normal prostate tissue growth or of prostate cancer growth.)
The current theory as to how testosterone affects the prostate is the “saturation model.” The receptors for testosterone are completely occupied (saturated) at a testosterone level of about 300. Thus, if testosterone levels go from 300, to 600, to 900, no more gets into and affects the prostate. As an illustration, if you soak a sponge in water, and then throw it in the ocean, it is not going to get any wetter than it was before.
This “saturation model” is supported by the fact that PSA levels (but not prostate cancer occurrence) increased when a man goes from significantly below 300 to 300 with treatment. However, PSA does not continue to increase after 300 is reached.
At this point, almost all major urological cancer centers and specialists are quite comfortable instituting TRT in men who have undergone radical prostatectomies, with clear margins, and no residual prostate cancer. In fact, some centers are even comfortable with TRT for men with documented prostate cancer undergoing a surveillance rather than treatment protocol.
Certainly, men without a diagnosis of prostate cancer should feel comfortable beginning TRT without worrying about increasing their chances of developing an enlarged prostate or prostate cancer.
Cardiovascular Risks of Testosterone Replacement Therapy (TRT)
Multiple research studies have shown that TRT actually has a beneficial effect on cardiovascular status. These have been recognized by both the American Endocrinological Society and the American Urological Society.
Our experiences, which are of course anecdotal since we are only one center, have been that TRT can have remarkably positive effects on cardiovascular status. Many, if not most, men with low testosterone levels have great difficulty in getting themselves to exercise and watch their weight. When they do, they have poor results and give up. With a higher testosterone level, their energy levels improve, giving them more motivation to exercise and diet, and much better results for the same effort. They “spiral up.” We have seen remarkable changes in absolute weight but more importantly increases in muscle mass and decreases in body fat. We have seen blood pressure, average blood sugar levels (HbA1c), and cholesterol levels decrease. This is on top of the other positives our patients are seeing (i.e. increased libido and energy, and better erections and mood.)
So, why the controversy on this issue? In December of 2013, two papers came out potentially linking the initiation of TRT with an increased risk of developing strokes or heart attacks. There were many serious flaws associated with both of these studies. One has, in fact, been mostly retracted. Since then, both the American Endocrinological Society and the American Urological Society have recognized multiple research studies showing that TRT actually has a beneficial effect on cardiovascular status. Of course, lawyers will continue to look for patients for possible class action suits against drug companies manufacturing testosterone. This kind of thing may make the news, but it doesn’t make it sound science.
Potential Side Effects from TRT
It is possible, especially within the first few months of treatment, for a man to retain fluid. This usually resolves itself on its own.
Shut Down of Sperm Production (partial or complete)
Spermatogenesis (the production of sperm) in all men is dependent on production of testosterone by the testes. If testosterone is given from outside the testes (exogenous testosterone), as in testosterone replacement therapy, the testes will then stop producing their own testosterone. This will actually shut down sperm production either significantly or completely in almost all men. This may be a temporary or permanent effect.
It is very important that younger men who still plan to have a family take this into account. Physicians specializing in TRT and fertility can manage men with low testosterone in other ways; ways that cause men to increase their own production of testosterone. This can be done at the pituitary level (clomiphene citrate) or at the testicular level (HCG.)
In our experience, men feel better on either clomiphene citrate or HCG than they did at their baseline. However, they usually do not feel as well as they would on pure testosterone. Thus, at Maze, our patients can “bank” their sperm (for more information on this subject, visit Maze Laboratories) and then begin TRT.
Sleep apnea is a condition in which an individual stops breathing for periods of time while sleeping. This can have significant medical effects. In the past there have been reports that increased testosterone levels exacerbate pre-existing sleep apnea. However, there is no recent data that supports this.
The severity of sleep apnea is very much dependent on a man’s weight, among other factors. In our experience, since most lose body fat with TRT, their sleep apnea may actually improve.
Increased Estrogen Levels
Testosterone is converted into estrogen by an enzyme called aromatase. Thus, the more testosterone there is in the body, the more estrogen. It is unclear at what level, if any, increased estrogen becomes an issue for men. Thus it remains controversial whether men who have an increase in their estrogen levels because of TRT need treatment.
In rare cases, men can respond to increased estrogen levels by developing some breast tissue. The vast majority of the time, the first sign of this is not visually noticing breast growth, but by developing some breast or nipple tenderness. In these cases, a medication which inhibits aromatase (the enzyme that converts testosterone into estrogen) is given. This almost invariably stops the breast and nipple tenderness, and reverses any breast growth that has occurred.
Increased Red Blood Cell Concentration (Polycythemia)
One of the most important side effects of testosterone replacement therapy can be an increase in the number of red blood cells (RBC’s) in the blood itself. The percentage of the blood made up by the RBCs is called the “hematocrit.”
RBC’s carry the oxygen, and thus increasing the RBCs increases the oxygen carrying capacity of the blood. (Some athletes illegally engage in “doping” which involves giving themselves a transfusion of their own blood, in order to increase the exercise capacity before a sports event.)
Because it increases their number of RBC’s, men with anemia (low percentage of RBC’s in the bloodstream) often benefit from TRT. We have had patients come off of expensive anemia drugs with the use testosterone.
However, if this percentage (HCT) becomes too high, it may cause a thickening or sludging of the blood, which may cause increased strokes, heart attacks, or blood clots.This percentage is not well defined, but most experts feel that a man’s HCT should not be greater than 55%. This is why we check every man’s HCT every three months, while on TRT. We encourage our patients who increase their hematocrit to donate blood, which almost always takes care of the problem. For some men who are not allowed to donate blood (either because of travel or medical history) we will sometimes draw blood from his arm, just as in blood donation, but dispose of it instead. This is referred to as a “therapeutic phlebotomy.”
Though we monitor men rigorously for this, we have found that very few develop too high a HCT, and all can be managed by blood donation, therapeutic phlebotomy, or a combination of both.
Hormone replacement treatment is started for a variety of reasons, but it is usually maintained for life. Since patients must be monitored for the duration of time that they are on testosterone replacement the monitoring is a lifetime commitment. However, if you stop TRT, you will no longer need monitoring.
Blood Tests and Follow-up
There’s still differing thought about how men with testosterone replacement should be monitored. It’s clear that if you’ve begun testosterone replacement for a particular symptom, that symptom should be carefully observed. For example, a patient using testosterone because of problems with osteoporosis should have regular serial bone density screens. Patients with mood or libido changes must be carefully evaluated, too.
Once TRT has begun, hormone levels are rechecked after one month of treatment. We also review symptoms with patients (but often don’t see any symptomatic changes at one month.) If levels are not adequate, increased testosterone is prescribed, and levels are rechecked after one month.
Once a patient is on an established regimen, we see him every three months, to monitor blood work and symptoms.
What Are We Aiming For?
Obviously, the ultimate goal is to make men healthier and to have them feel and function better.
In terms of testosterone levels, we aim to be in the “high normal” range. It is unclear what level of testosterone is “too much.” However, we have found that most men feel better at “high normal” levels rather than at “mid-range” levels.
When Will I Notice Any Changes from Testosterone Replacement Therapy (TRT)?
Most men will not notice any changes for the first couple of months on TRT. (The exception is that many men will notice an increase in the frequency and rigidity of morning erections relatively soon after starting.)
Many men come into their one month visit, convinced that they do not have an increased level of testosterone. Some of these men may be right, because, for example, the topical testosterone treatments may not be giving them good blood levels of testosterone. However, many men will have excellent levels, but not feel any different.
A few men will actually feel almost euphoric after beginning treatment. We get calls from men exclaiming, “I feel 18 again!!!!” However, it is not possible for this to last. Their body gets used to this higher level, and though they feel better than they did before, they will not continue to feel 18 forever.
In terms of symptoms, most men will notice:
- Increased Muscle Mass and Energy- at 4 months
- Improved Erections- at 6 months
- Increased Libido- at 9 months
Of course, every man is different, but we strongly feel that before beginning TRT, you should mentally commit to getting excellent levels for a year. We see many men who have tried TRT, but inadequately. They either do not get excellent levels, or do not stay on it long enough; usually both. They come in saying that TRT does not make a difference for them but it is almost always because they haven’t received or stuck with a proper treatment plan.
For about 90% of our men who get excellent hormone levels, and stay on their regimen for a year, TRT is a true game-changer.
More Information About Male Hormones or Androgens
Andropause is identified as a drop in androgens, the overall grouping of male hormones. They are made in the testes and in the adrenal gland (a small gland located above the kidney that produces a significant number of hormones). The main functions of androgens are:
- Initiation and maintenance of spermatogenesis, the signal in a man’s body to produce sperm.
- Determination, during pregnancy, that a fetus will be male.
- Sexual maturation at puberty, controlling sexual drive and potency
|Relative Androgenic Activity of Adrenal Androgens|
In men, androgens are known to affect muscle, bone, the central nervous system, prostate, bone marrow and sexual function.
We know that testosterone causes “the androgenic effects,” determining and shaping the male reproductive tract in an infant as well as the development of secondary sexual characteristics (i.e. body hair and male pattern baldness). In addition, androgens are responsible for prenatal differentiation of the male fetus and for the development of the male reproductive tract. Androgens play an important role in stimulating and maintaining sexual function in men. Testosterone is necessary for normal libido, ejaculation, and spontaneous erections.
Anabolic effects are those that promote growth. They affect other tissues such as muscle mass and bone density. Androgens increase lean body mass and affect body weight as well. Androgens are required to maintain bone density in men. It is still not clear whether it is the androgens themselves that are needed to affect the bone or whether it is just important that they be present so that when they are converted to estrogens, the estrogens have an effect on the density of the bones.
Androgens can affect red blood cell production and they appear to have an effect on blood fats and cholesterol. The most well-known effect of androgens is their effect on growth of the prostate. They affect both the non-cancerous and potentially cancerous cells in the prostate. There is no evidence that, after a man reaches a testosterone level of 300, additional testosterone plays an additional role.
Androgens also play an activating role in cognitive function throughout life, keeping men sharp and alert. The relationship between androgens and mood is still unclear, but in-depth exploration has begun.
If you have andropause, you may be wondering how you got it. Other factors may be contributors, but the primary one is that as men get older, their testes and adrenal glands don’t work as well.
Other reasons are that the organs that produce testosterone just aren’t creating as much testosterone and more of that testosterone is being converted to other hormones like estradiol and DHT.
Specialized cells in the testes, called Leydig cells, make testosterone. As an adult male you produce about five grams of testosterone per day. You do this in bursts and there is a daily pattern, with a peak occurring early in the morning and a low point in the late evening.
Only certain cells in your body can receive the testosterone and a number of these cells later convert the testosterone into Dihydrotestosterone (DHT). DHT is three times as potent as the testosterone itself. Interestingly, the testosterone can also be converted into estrogens (the main female hormone). This occurs particularly in fat cells.
Most testosterone in the body is bound or “attached” to proteins. Thirty percent is bound to a type of protein known as sex hormone-binding globulin (SHBG). The testosterone binds very tightly to SHBG, which has a tendency to increase as men age. The remaining testosterone is bound much less tightly to other proteins in the blood, the most prevalent being albumin.
Two percent of the testosterone is unbound (not attached to any other protein) and is called free testosterone. Free and albumin-bound portions of testosterone make up the measure known as “bio-available testosterone.” This is the testosterone that is seen in the tissue and that has the most effect on the body. So, any change will affect the total amount of available testosterone. The amount of SHBG, or blood proteins, also will affect the amount of available testosterone and will have an effect on the body.
As you get older, your SHBG increases, meaning you have less available testosterone. Other hormones can affect SHBG, too. Elevated female hormones and thyroid hormones will increase SHBG, which will then, in turn, affect the bioavailable testosterone.
The symptoms that are associated with a loss of androgens may also be caused by decreases in other hormones, so testosterone replacement may not completely resolve all of the issues. However, at this point, there appears to be good evidence that testosterone replacement can improve many of these symptoms.
Many of the active androgens in the body are not produced by the testes but by the adrenal glands. The major androgens created by the adrenal glands are DHEA, DHEA-S, and androstenedione. Although these androgens are not very strong, they are converted to the much stronger androgens: testosterone and DHT. However, they are a small percentage of the total androgens available in men. In men, the adrenal gland secretes approximately 3 to 4 mg of DHEA per day, 7 to 14 mg of DHEA-S per day, and 1 to 1.5 mg of androstenedione per day.
The adrenal steroid, DHEA-S, is the most plentiful steroid in circulation in the body. The amount of DHEA-S concentrated in the body is very dependent on age. Men have the most in their 20’s and 30’s. By their 70’s, men’s DHEA-S levels are down, on average, to twenty percent of its peak level.
Interestingly, while there has been a lot of research, we still don’t know a lot about what DHEA-S does in the body. However, we think it has a “protective” role. It seems that the higher the DHEA/DHEA-S level is, the lower the incidence of cardiovascular disease and various forms of cancer, as well as many other aspects of cellular aging.
DHEA is considered the “mother” hormone. It is the hormone in the body that is later converted into other hormones, including testosterone. DHEA is first produced in children at the age of seven years. It reaches its peak production for men in their teens and twenties. From that point, it slowly decreases over a lifetime. Synthetic DHEA is widely available and widely used and it appears to be relatively safe. However, right now we don’t know whether or not it is effective in creating any changes in the aging male, though some studies do indicate that men with higher DHEA levels live longer.
Growth hormone levels control the production of insulin-like Growth Factor 1 (IGF-1) that affects the body’s composition, lean body mass, and bone density. As growth hormones decrease, so does IGF-1. Growth hormone production decreases after puberty at a rate of approximately 14% every 10 years. This decrease in growth hormone is called somatopause (similar to the decrease in androgens being called andropause). It appears that administration of growth hormone can help improve body composition with increases in lean body mass and bone density.
However, little is known about the efficacy and safety of growth hormone. There are studies that indicate it may increase the risk of diabetes and cancer.
In our practice, we will often check an IGF-1 level. If it is normal, we do not treat with growth hormone.
The pituitary hormone that stimulates the thyroid to make thyroid hormones is called TSH. As men get older, TSH decreases and the thyroid becomes less responsive to TSH. There is a decrease in the circulating amounts of thyroid hormones, and this may result in symptoms of hypothyroidism or decreased thyroid in the elderly. Decreased energy, metabolism and mental acuity are some of the symptoms. It is estimated that close to 20% of elderly men suffer from these symptoms.
We check TSH and free T3 levels in all men. If TSH is elevated beyond 10, this is a clear indication that the thyroid is failing, and thyroid hormone supplementation should be started. There is considerable controversy about whether to supplement men with thyroid hormone when their TSH is between 4 and 10.
If the active thyroid hormone levels are reduced, this is another indication for treatment.
Determining your Aging Male Symptoms Score (AMS) is a simple and effective way to detect whether you may have andropause. Based on a set of 17 factors, the score is designed to determine whether there is a general indication for andropause. If you are concerned that you may have andropause, simply score yourself using the form below. You can also download the Aging Male Symptoms PDF and score yourself, and take it with you when you visit your doctor.
Each item is rated on a scale from 1 to 5; 1 represents an absence of symptoms, and 5 represents those that are extremely severe. Simply rate each item on the scale, then add up your score. There are 17 in total, so the minimum score is 17 and the maximum score is 85.
It’s important to keep in mind that having some of these symptoms isn’t necessarily an indication that you have andropause. They could be related to some other cause, so a blood test is the best way to make a diagnosis.
The best way to complete the form is to not overthink each item.
|Decline in your feeling of general well being (general state of health, subjective feeling)|
|Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)|
|Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)|
|Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early and feeling tired, poor sleep, sleeplessness)|
|Increased need for sleep, often feeling tired|
|Irritability (feeling aggressive, easily upset about little things, moody)|
|Nervousness (inner tension, restlessness)|
|Anxiety (feeling panicky)|
|Physical exhaustion/lacking vitality (general decrease in performance, reduced activity, feeling of getting less done, of having to force oneself to undertake activities)|
|Decrease in muscular strength (feeling weak)|
|Depressive mood (feeling down, sad, on the verge of tears, mood swings)|
|Feeling that you have passed your peak|
|Feeling burnt out, having hit rock-bottom|
|Decrease in beard growth|
|Decrease in the number of morning erections|
|Decrease in ability/frequency to perform sexually|
|Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for intercourse)|
The implications of your score are as follows:
- 26 or less means that you have no significant symptoms consistent with a low testosterone
- 27-36 means that you have mild symptoms consistent with a low testosterone
- 37-49 means that you have moderate symptoms consistent with a low testosterone
- 50 or greater means that have severe symptoms consistent with a low testosterone
We suggest that your hormone levels be tested if your score is 27 or greater.
The diagnosis of Low T/Andropause is and will remain controversial for the foreseeable future. However, it must always include a thorough evaluation of symptoms and laboratory data.
The symptoms have been described above. There are several validated questionnaires for the diagnosis of Andropause. We feel that the most comprehensive but user friendly one is the AMS.
In our center, we are truly concerned about your overall health, both physical and psychological. As a result, you will complete multiple questionnaires which we will review with you, including:
- Overall Medical Health
- AMS (Aging Male Symptoms)
- Erection and Sexual Function
- Depression and Anxiety
- Prostate and Urination Symptoms
We will take a careful and thorough history of what brought you to see us in the first place, how you are doing in general, both physically and psychologically.
If we determine that you have the symptoms of andropause, then it is important to have your blood work tested.
Blood Work/Hormone Levels
Low testosterone must be diagnosed by a medical professional. Many diseases and conditions may share symptoms and a medical professional who specializes in low testosterone will be able to identify the issue and create a treatment protocol. The doctor will interpret medical test results in conjunction with your physical symptoms.
If you have significant symptoms, consistent with a low testosterone, but have a normal testosterone, we will try to figure out what could be causing these symptoms. (i.e. Diabetes is one possibility.) If we can’t help you address them, we will refer you to the appropriate specialist(s). With our team approach, we have been able to help most men, many of whom do not need an outside referral.
Testosterone (T) Testing
There are several aspects of testosterone that make both testing and interpretation difficult:
A man’s testosterone production, and thus blood levels, are not consistent throughout the day. In general, testosterone levels are higher in the morning and then decrease throughout the day. This variability is more pronounced in younger men and decreases as we age. In other words, for younger men it makes more of a difference what time their testosterone is measured than it does in older men.
For men under 45 years old, it is suggested that testosterone levels be measured before 10 AM. In our practice, we screen men at their first visit, no matter what the time. If the testosterone is borderline or low, we repeat it prior to 10 AM.
In men older than 45, there is significant debate as to how important it is to measure the testosterone level in the morning. Thus, we are not as concerned about what time the blood is drawn with this age group.
There is a lot of variability in a man’s testosterone levels. The same man, or an older man, can have quite different testosterone levels throughout the day or at the same time of day on different days. Thus, the diagnosis is never made based on only one testosterone level measurement. If the second test is significantly different from the first test, a third may need to be performed. We have had many patients, with significant symptoms, whose first testosterone was “low-normal”, whose repeat testosterone was quite low and whose third test confirmed that it was, in fact, quite low.
>Changes With Age and Differences Between Individuals
For all men, testosterone levels decrease with age. Again, every man is different, but it is thought that, for most men, this decrease may start as young as 25!
Many men with a “low-normal” testosterone level will ask, “How do I know what my levels were when I was younger? Maybe this is quite low for me!” There is a certain legitimacy to this. These men may indeed feel much better and more like themselves with a higher testosterone. Thus, we are always using a combination of blood work results and the clinical situation to make the decision as to whom to treat and how high their levels should go.
Why Do There Seem to Be So Many Different Testosterone Measurements?
When reading about testosterone, you will see various measurements referred to. These include:
- Total Testosterone
- Free Testosterone
- Bio-available Testosterone
- Free Androgen Index
The most important thing to realize is that the Total Testosterone measures all of the testosterone that is in your blood stream. However, most of that testosterone is bound to proteins. Any testosterone that is bound forms a complex that is too big to get out of your blood stream. Thus, it is not free to go into the cells themselves, and is not useful to your body. You will not benefit from it. The most important of these proteins is Serum Hormone Binding Complex (SHBG.) SHBG binds tightly to testosterone, and takes it out of commission. Thus, if you have a low normal testosterone but high SHBG, the amount of testosterone your body can use is low.
SHBG levels increase as men age. Men with liver issues or on chronic opioids will have high SHBG. Men with high female hormones or thyroid issues may also have an increased SHBG. Some men without any known risk factors have high SHBG.
Traditionally, these men are under-diagnosed and under-treated. In order to diagnose these men, a testosterone measurement that takes into account SHBG must be performed.
Are Different Labs Different When It Comes To Measuring Testosterone?
Studies have shown that there is a huge variation in results from lab to lab specifically when dealing with testosterone. Not only do different labs perform different testosterone measurements (i.e. free testosterone versus free androgen index), they do it in different ways. It is important to have a specialty laboratory test the hormones and to use the same laboratory every time the blood is tested. Once you have begun treatment, you will want to know not only where your levels currently are, but how those levels relate to where you started!
What Constitutes A Low Testosterone Level?
There remains significant controversy as to what represents a “low“ testosterone level. It is well accepted that a man with symptoms and two testosterone levels below 300 ng/dl (nannograms per deciliter) has a low testosterone and should be considered for treatment. The far more complicated question comes with regards to what constitutes a “normal” testosterone level.
What Does “Normal Testosterone Level” Mean?
First of all, it is important to understand what “normal level” means in the context of any lab value. Traditionally, this means that your levels fall within the range for 95% of men. If your levels are abnormal, then you are in either the lowest 2.5% or the highest 2.5% of all men. This means that in order for your testosterone to be reported as “low”, you must test lower than 39 out of 40 men.
“Normal” is also different than “optimal.” For example, we do not want men to have a “normal” cholesterol. We want them to be in a range where they are least likely to have cardiovascular events. “Normal” is not our goal, “optimal” is!
Separately, there is another issue with “normal” levels that have been determined, as mentioned above, by seeing where the range within which 95% of men fall. These levels are not stratified by age! We know that as men age, testosterone decreases dramatically. However, this is not taken into account when looking at the reference ranges. Should a 30 year old man have the same estimation of “normal” as a 75 year old man? Obviously, not.
For example, in one large study, the mean testosterone for men 25-29 was 669. However, even more importantly than the mean, is where does a certain level put you compared to other men in your age cohort? For men aged 25-29, if your testosterone is 438 or less, you fall in the lowest 10% of men for your age group. If your testosterone is 388 or less, you fall in the lowest 5% of men in your age group. It would make sense that you may not feel great, even if your testosterone level is “normal” by standard criterion which considers any level of over 300 as normal. Should a symptomatic 27 year old man with an average testosterone level, using morning readings of less than 425 be treated? We think yes, and our experience has borne this out.
Is My Testosterone Low For Me? Some of the things we simply don’t know
Most men do not have their baseline testosterone levels measured. They are usually only measured once a man starts complaining of symptoms.
If a man had a testosterone level of 900 for most of his life, and now is at 420, will he feel worse than previously? Almost undoubtedly, yes. Will he feel worse than a man who started at 700 and is now 420? We don’t know the answer. Is how he feels a ratio of his baseline testosterone to his current testosterone levels, or is it the absolute number? We don’t know!
Why do some men feel dramatically worse as their testosterone levels fall, and some men not notice the difference? We don’t know!
Why are some men exquisitely sensitive to their levels, and feel good only within a certain narrow range, while for others once they reach a certain level they notice no differences as the levels go up and down? We don’t know!
What we do know, is that most men with significantly lower than average levels, but still within the “normal” range (the middle 95% of men their age) will feel better with a higher testosterone level.
How Common is Low T in Men?
ADAM, or andropause, is a fairly common condition and the incidence of andropause increases with age. Roughly 2-5% of men age 40-49 years have it. Between 6-40% of men age 50-59 years have it. Roughly 20-45% of men age 60-69 years have it. Roughly 34-70% of men age 70-79 years have it. Roughly 91% of men older than 80 have it. The spread of estimated ranges is quite large because different specialists use different ways to measure androgens and use different minimum levels to define andropause. The important thing is that if a patient feels there are reasons for concern, he should visit a doctor to learn more.
Andropause is rarely a sudden condition; symptoms develop gradually, over time. The three main symptoms are:
- Decreased/low libido (little or no interest in sex)
- Erection issues
- Decreased energy, muscle mass, and strength
Other symptoms, all of which are significant and all of which may be positively affected by treatment, include:
- Osteoporosis (which can lead to increased bone fractures and breaks, as well as a decrease in height)
- Mood changes
- Intellectual focus and mental acuity changes
- Decreased body hair
Understand that these are symptom guidelines. Andropause affects different men in different ways and to different degrees. There are men who may get one or two of these symptoms, and may just notice the other symptoms occurring minimally or not at all.
Decreased/Low Libido (Little or No Interest in Sex)
Libido is shockingly physiological. Almost all men will have a lower libido as their testosterone levels decrease. Almost all men will have a higher libido when their testosterone levels increase.
Libido can be diminished overall, or diminished in a particular situation. A generalized decrease in libido usually means that a man loses interest in all kinds of sexual activity and in all contexts. However, a less generalized decrease may lead a man to notice that he has less interest in masturbating or he has less of an attraction to women/men that he sees or works with.
A decreased libido can be quite devastating for a man and his partner. Popular culture projects that all men should want sex all the time. This is untrue, of course, even for men with good libidos. But when a man’s libido is significantly reduced, his partner often feels rejected. (i.e. Do you find me unattractive? Are you having an affair?)
If a man has a generalized decrease in libido, it is important that he communicate this to his partner. This will help her/him to feel less rejected personally, and to put the situation in a more medical context.
In many cases,a lack of interest in sex with a partner may be due to a number of factors; an overall decrease in libido combined with relationship issues, for example. These issues must, of course, be addressed as well.
Erection issues are strongly correlated with decreased testosterone levels.
The first thing that men may notice is a decrease in the frequency and rigidity of their nocturnal or morning erections. (Interestingly, this is often the first thing men notice improving when their testosterone levels are increased through treatment.)
More importantly, men may find they are having true erectile dysfunction, with difficulty achieving and maintaining an erection during relations. Erectile issues have many possible contributing factors, but a low testosterone is a significant one. There are physiological changes in the penis that result from changes in testosterone levels. Lower levels cause decreases in penile muscle and increases in fat and fibrotic tissue, making it harder for blood to flow to the penis and be trapped there. (Conversely, increasing testosterone levels causes an increase in penile muscle and a decrease in fat and fibrotic tissue.)
Decreased Energy/Muscle Mass/Strength
As men get older, energy levels, muscle mass, and overall strength decrease. However, this process is accelerated by decreased testosterone, and partially reversed by increasing testosterone. It is important to note that a 60 year old man is not going to be 18 again! (This is why it is important to view “anti-aging” clinics with suspicion). However, it is also true that the vast majority of men with low testosterone levels who receive treatment will have a partial reversal of these symptoms.
It is also important to recognize that decreased strength and muscle mass (and, conversely, increased body fat) has significant negative implications for your overall health. Most men gain much of their weight around their waist. Some of this fat is simply subcutaneous (underneath the skin.) However much of it surrounds internal organs. This fat is particularly harmful. Beyond contributing to the negative effects of other body fat, it is also hormonally active in many negative ways. Increased body fat correlates strongly with diabetes, blood pressure, cardiac disease, and osteoporosis. We are increasingly learning how dangerous it is.
As you work your way through this website, take the Aging Male Symptoms (AMS) Questionnaire if you’re concerned that you might have andropause. It’s a simple and effective way to detect this condition. However, keep in mind that just because you have a few of these symptoms doesn’t necessarily mean you have andropause. It could be some other cause, so a blood test is the best way to make a diagnosis.
There is little agreement about “normal” female testosterone levels. If a woman goes to a general physician and is told that her testosterone levels are “normal”, all that means is that they are in a range of women who are not ill. It does not mean that the levels fall into a range that she needs for optimal health and functioning.
The medical community began researching and treating women with androgens (DHEA-S or testosterone) in the 1990’s. There is more and more research attesting to its efficacy and safety. And significant research continues in this area. As a result, “normal levels” are being established, though there is still a great deal of debate about the limits for each age. Each specialist in the field might have a slightly different range and may use different measurements for diagnosis including total testosterone, bio-available testosterone, free androgen index or free testosterone. Also, many specialists depend almost exclusively on symptoms, rather than blood levels.
A woman who would like her testosterone (and other hormone levels) assessed in order to better understand their effects on her sexual and overall health should find a specialist in the field of female sexuality. The specialist should get a thorough history and place these results in a medical context. Any specialist that realizes the complexity of female sexuality will have a range of options for treatment/management available, including but not limited to hormonal treatment.
We are very proud of our WOMEN’S CENTER staffed only by women, which provides a comprehensive, scientific, and warm atmosphere for women to address their sexual health.
In A Patients Own Words:
When I came to see Dr. Werner, it was for a combination of erectile dysfunction and andropause. I had been seeking help for 10 years, trying different solutions, with very little success. I was put on Viagra at one point, which worked great at first, but it had side effects that I wasn’t happy with at all. I started searching on the web for options, and found Dr. Werner.
My first impression of him was how transparent and truthful he is. He consults with you on a very personal basis. He is so consistent with his quality of care, and always looks you in the eye when you speak with him. My treatment was individual to my issues, and Dr. Werner has so many tools to use to help you.
My sex life has totally improved. I had problems, and Dr. Werner was the solution. I recommend him to anyone that is having problems with their sex lives. He is not just “some guy” that will prescribe you a pill and walk away. I am so happy I found him, and my life has changed for the better.
– Jon –
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