Replacement testosterone

DEAR DR. ROACH: I am a 69-year-old male with very low testosterone levels. My doctor started me on a testosterone cream and increased the frequency of application twice, trying to get my testosterone blood levels to “normal” without success.

He then switched me to injections, increased the amount of the injections, then the frequency, and finally settled on 200 mg, every three weeks.

The problem is that I don’t feel like I need the “normal” levels of testosterone; the very lowest frequency of the cream is sufficient for me. It makes me more ambitious, and I add muscle mass more readily with exercise.

Is there some benefit to the higher “normal” levels of testosterone? Or can I just go with the lower dosage and the lower blood levels that result?

ANSWER: Testosterone replacement is given to men with symptoms of low testosterone who also have low testosterone levels as evidenced by laboratory tests.

Common symptoms of low testosterone include low libido and erectile dysfunction, decreased bone mineral density and loss of body hair.

The loss of muscle mass and fatigue you mention also may be due to low testosterone, but those symptoms are less specific.

There are two reasons to treat low testosterone: One is to relieve symptoms; the other is to treat or prevent metabolic problems, such as the loss of bone and possibly harmful effects on blood cholesterol levels.

Returning blood testosterone levels to normal, as your doctor recommended, is the best goal.

While your symptoms may get better with only a small dose, it’s possible that you are having a placebo response (i.e., you’re getting better because you think you should be getting better, not because of the medication).

I think you will get more benefit from levels in the normal range. Some people have side effects, so your doctor has to find the optimum level for you.

DEAR DR. ROACH: Recently, I had an ultrasound on my gallbladder and liver, mainly to check on a polyp found on my gallbladder six months ago. There was no change in size, so my doctor isn’t concerned.

However, the ultrasound showed that I have an abdominal aortic dilation/aneurysm (2.9 cm). My doctor doesn’t seem too concerned, suggesting that I follow a healthy diet and lose some weight (I’m overweight by about 30 pounds).

She said I’ll have another ultrasound in a year. After looking up the condition online, it sounds rather serious.

ANSWER: The aorta is the largest blood vessel in the body, coming directly off the left ventricle of the heart, arching in the top of the chest to provide blood to the head and arms, then progressing down the body, providing blood to the abdominal organs before it divides into the femoral arteries (to the legs) at about the level of the bellybutton.

The aorta can become enlarged (dilated), and when large enough, it is referred to as an “abdominal aortic aneurism.”

Rupture of an AAA is disastrous: It usually is fatal, so when it is recognized, it is watched and intervention is undertaken before it becomes a high risk for rupture. AAAs are more likely in men, and the major risk factors are smoking, atherosclerosis (fatty deposits and calcium in the blood vessels) and connective tissue diseases, such as Marfan’s syndrome.

Men between the ages of 65 and 75 with any history of smoking should be screened for an AAA. An ultrasound is a quick, safe, reliable way of screening.

The diagnosis of an AAA depends on size: For most women, a level of 3 cm is a reasonable cutoff. You are just below that, so I understand why your doctor may want to check up on it again.

Assuming you don’t smoke (quit now if you do), then it’s most important to control your blood pressure. A diet with plenty of fruits and vegetables was found to be protective against AAA. Being overweight or obese may increase risk, so work with your doctor on losing the extra weight.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.