October 2, 2012

October 2, 2012
When Testosterone Replacement
Doesnít Lead to Better Erections

Welcome to another day in my life. Today is Tuesday and I hope you are having a safe and great week so far. It is another busy week for Dab the AIDS Bear and me.

For most men, testosterone levels become a problem as they get older since the levels decrease with age. It is even harder on men living with HIV/AIDS especially long term survivors of HIV/AIDS.

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. So, some men need some extra help to make sure that their improved sex drive matches an improved and hard erection.

Before we start covering other options for improving erections, letís talk about steps you should take before you start combination therapy of testosterone plus other options. If erectile dysfunction or sex drive is not improved while on testosterone, ask your doctor about adjusting your dose of testosterone. Ensure that your total testosterone level is between 500 and 1000 ng/dL. Also, have your doctor check your blood levels of estradiol and prolactin.

High estradiol blood levels caused by conversion of testosterone into this female hormone by the aromatase enzyme may cause sexual dysfunction (this can be treated with low dose anastrazole). So is high prolactin's effect on erectile function. Low levels of thyroid hormone, infections, lack of sleep, alcohol, smoking, medications and depression also can cause erectile dysfunction in the presence of normal testosterone levels. Blood pressure medications are known to be one of the main causes of erectile dysfunction, so discuss the different type of medications to keep your blood pressure in normal ranges (high blood pressure is also a risk factor for erectile dysfunction). Last but not least, lack of attraction for our sexual partner can get in the way of achieving a strong erection.

If high estradiol of over 30 pg/dl is found (by ultrasensitive testing), then anastrozole at 1mg three times a week may be enough to bring it down to healthy levels. Remember that estradiol is important for men to keep healthy skin, hair, and brain function. High prolactin can be treated with cabergoline.

HCG- As mentioned before, human chorionic gonadotropin (HCG) mimics LH and stimulates the Leydig cells of the testicles to produce testosterone. HCG has been successfully used alone or in combination with testosterone replacement to normalize testicular size after long term anabolic steroid or testosterone use. It has also anecdotally helped men whose sexual drive does not improve on testosterone replacement alone.

No published studies have been done on this benefit, however. Doses of 250-500 IU twice a week while on testosterone replacement are being prescribed by several physicians who report that their patients perceive improvements in sexual desire and erectile function on this regimen. We do not know if this effect lasts after long term HCG use or if it is better to cycle it on and off.

PD-5 Inhibitors- For many older men the use of prescription phosphodiesterase type 5 inhibitor (PD-5) medications like Viagra, Cialis, and Levitraómay 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 Claritin and ibuprofen with these drugs to pre-treat nasal congestion and headaches, respectively.

Sildenafil (Viagra) was the first PDE5 inhibitor to enter on the market in 1998. The usual dose of sildenafil is 50 mg (25 to 100 mg) taken one hour before sex. The effects of sildenafil last for approximately four hours, and patients should be instructed to use no more than one dose within 24 hours. Fatty meals reduce the absorption of sildenafil; therefore, the drug should be taken on an empty stomach. This may be an inconvenient factor that needs careful planning of which some patients are not aware.

Vardenafil (Levitra), the first second-generation PDE5 inhibitor to be developed, is given at a usual dose of 10 mg (2.5 to 20 mg) one hour before sex. Older men and those with moderate liver dysfunction should receive a lower initial dose of 5 mg. Vardenafil begins working within 30 to 45 minutes after administration and lasts for about four hours. As with sildenafil, patients taking vardenafil should not use more than one dose within a 24-hour period. Patients should not take vardenafil within three hours of fatty meals, due to a reduction in absorption.

The newest PDE5 inhibitor is tadalafil (Cialis), which has a longer duration of action--approximately 36 hours--than sildenafil or vardenafil. In addition, the usual dose of 10 mg (5 to 20 mg) should be taken about 30 minutes before sexual activity. This shorter onset time can possibly allow patients more opportunity for spontaneity. Food intake does not appear to affect the absorption of tadalafil; this makes it very practical for men who do not plan ahead when they have sex. Cialis is approved for low dose daily use, but most insurance companies will not pay for it. If you want to try a 5 or 10 mg dose daily, you can get a free 30 day supply after getting a doctorís prescription and taking the following voucher to your pharmacy after downloading it and printing it (you have to answer some questions online first). You are better off asking your doctor for a prescription for 10 mg per day and cut the pills in half for the first week to see if 5 mg per day works well enough for you.

Though considered generally safe for most patients, including those taking multiple antihypertensives, PDE5 inhibitors are not a viable treatment option for every man with ED. They need to be used with careful monitoring in patients with a cardiovascular history that includes heart attacks or stroke (within the past two weeks) and hypotension (blood pressure <90/50 mmHg), Because PDE5 is inhibited in penile tissue as well as extra genital tissue, patients treated with PDE5 inhibitors may experience headache, facial flushing, nasal congestion, dyspepsia, and dizziness. Sildenafil also inhibits PDE type 6 in the retina. Therefore, patients treated with sildenafil may experience sensitivity to light, blurred vision, and loss of blue-green color discrimination, all of which are generally considered reversible. Tadalafil also inhibits PDE type 11 in skeletal tissue, possibly leading to back and muscle pain.

ED drugs 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).

Tomorrow I will continue this blog and cover more of the issues and possible solutions.

Hope you have a beary great and safe Tuesday!

Until we meet again; here's wishing you health, hope, happiness and just enough.

big bear hug,

Daddy Dab