From the book: Built to Survive, available at medibolics.com and amazon.comBlood Testosterone Levels And HIV-POSITIVE Hypogonadal Men
The Normal Scale Doesn’t Seem To Apply
As was stated in the sectionon lipodystrophy, the standard “normal” range for total testosterone blood levels, may be too low for HIV-POSITIVE people. In an article in the Body Positive newsletter (May 1994, p. 22) regarding hypogonadal HIV-POSITIVE men, progressive researcher Judith Rabkin, Ph.D. of New York City, stated that in her study “those who experience significant improvements in sexual functioning tend to have higher serum testosterone levels, usually between 1000 and 1900 ng/dl….” (Remember the normal scale for men is generally about 300 to 1000 ng/dl.) In private correspondence Dr. Rabkin stated that a few of the men in her study did respond at blood levels that were as low as 700 to 800 ng/dl. The important point is that “normal” is a relative term when all things are considered.
We suggest that if the patient is not responding appropriately to testosterone doses that delivers blood test levels in the low and even mid-range of the normal scale, the physician should consider working with doses that deliver testosterone blood test measurements that register in the high end and sometimes above the upper limit of the “normal” scale. Optimum dosing can be very individual and it is best to work with the patient and find the dose that gets the desired effects of improvement in lean body mass, functional strength, energy, mood, increased appetite, and sexual function. Physicians might also consider that the “normal” scale may be an inadequate measurement for HIV-POSITIVE people in general, whether they are hypogonadal or not. Thus we suggest that the physician listen to the patient themselves rather than relying solely on the standard testing mechanisms and scales when making a determination of whether to prescribe testosterone replacement therapy and what supplemental hormone dosage will be found to be optimal. For women, the physician should exert great care in finding the optimal dose without overdosing, as excessive testosterone levels can virilize women, as women are significantly more sensitive to testosterone (and other anabolic steroids) than men.
Measurements - Free And Total Testosterone - Men And Women
While "total testosterone" is frequently the only measurement taken when hypogonadism is suspected, free testosterone, may be a more relevant barometer for assessment of HIV-positive individuals. For instance, free testosterone has been shown to be more correlative with lean body mass than total testosterone in wasting HIV-positive men 42 and women. 41 According to the Merck Manual, normal free testosterone measurements for men generally range between 3.06 and 24 ng/dl. For women the range is generally between .09 to 1.28 ng/dl. We suggest that it may be best to take both free and total testosterone measurements, but that free testosterone may provide more relevant information when addressing the patient's muscle mass and quality of life.
Hypogonadism and HIV Progression - Men and Women
With progression of HIV, hormonal changes have significant correlations with immune function. Studies show that decreasing testosterone function (hypogonadism) in HIV-positive people significantly correlates not only with loss of lean body mass, 41, 47 but also decreasing t-cell count, 47 and increasing morbidity. 49 And one recent study give indication that testosterone replacement therapy might decrease apoptosis in HIV-positive hypogonadal males. 43
In another men's study, DHEA, and free testosterone levels decreased as CD4+ T-cells decreased in all patients. The authors stated that hypogonadism occurred as the CD4+ T-cells decreased. 48 In this study, low levels of free testosterone were common in all HIV and AIDS patients, and total testosterone and androstenedione were lower in those patients whose CD4+ T-cells were below 200. DHEA (an adrenal androgen steroid) blood levels were decreased in patients with CD4+ counts below 500.
Therefore, we strongly suggest that the physician address hypogonadism, or decreased free testosterone by supplementing with weekly administration of testosterone enanthate or cypionate as continuous replacement therapy. We also suggest measuring DHEA-S (sulfate), and instituting DHEA supplementation if DHEA-S measures low. More information on DHEA appears later in the section on dietary supplements.
The Anti-Depressive Effect of Testosterone
We frequently hear HIV-positive people tell of how testosterone replacement therapy ended a long-time feeling of depression. One comparative study stated that testosterone replacement therapy produces equivalent effects to common anti-depressive drugs (imipramine, fluoxetine, and sertraline) in the treatment of clinical depression in HIV-positive people. 44 While testosterone is not specifically defined as an "anti-depressive agent”, restoring testosterone levels in hypogonadal patients can produce a powerful anti-depressive effect via its effects on neurological systems, 94 and dramatically improve feelings of "quality of life". Testosterone also has a very important effect on enhancing healthy libido for men and women. 80, 81 Dr. Judith Rabkin is now conducting a study to compare testosterone to Prozac.
For Hypogonadal People – Testosterone First
Those men and women who are on testosterone replacement therapy because they don’t produce adequate amounts of testosterone, or have low free testosterone levels, may need to employ cycles of anabolic steroids that are added to the person’s replacement testosterone if they lose weight for some reason. For these people, the higher dose anabolic cycles are periodically added to their regular replacement dose of testosterone, so that the total of the testosterone plus the additional steroid creates an “anabolic level” of the combined drugs that will produce best muscle growth during the cycle. After the cycle, the replacement testosterone dose should be resumed at a level that is sufficient to basically maintain their lean muscle mass, and quality of life. They may need to institute another cycle at some time due to a bout with a catabolic illness where they again lose weight. But some people only have to use one high powered “PoWeR” cycle to gain 30-40 pounds. From then on they stay on a replacement dose. Others need several cycles, but usually after they attain sufficient lean muscle mass, the proper testosterone replacement dose may be all that is necessary, unless there is a catabolic event.
Testosterone Patches - Men
Use of a testosterone patch like the Alza Testoderm or Smith/Kline Beecham Androderm, or the Alza Testoderm TTS products may be considered for those who need replacement testosterone therapy. For many men, a patch will usually effectively bring them into the midrange (650 ng/dl) of testosterone blood tests, and they will feel a significant improvement in libido, mood, and energy.
We don’t recommend patches for those who are wasting, as a study detailed at the NIH Wasting Syndrome Conference, May 20, 1997, at Bethesda, Maryland, showed that patches are not effective for treatment of HIV-wasting. While the patch is not an effective wasting therapy, it can improve basic quality of life for people who need basic testosterone replacement therapy.
We question whether there might be problems for some men with long-term use of Alza's scotal patch, as one review article stated that it causes dihydrotestosterone (DHT) levels to rise inordinately relative to the increase in testosterone because of the enhanced 5-alpha reductase activity in scrotal skin. 50 Elevated DHT increases the potential for prostatic hypertrophy, and hair loss. We also do not know if increased DHT would have a negative or positive effect on HIV-positive men's immune metabolism.
ALZA is now making the “TTS” version of Testoderm that delivers 6 mg. Of testosterone that can be placed on other parts of the body. While the Androderm patch can also be placed on other parts of the body, the Testoderm TTS patch is preferrable because it has a new high-tech non-sticky adhesive, so it doesn’t irritate skin the way the Androderm patch can. (A lot of people complain of pink irritated skin with Androderm.)
Testosterone Creams and Gels - Women and Men
We are in the beginning stages of reviewing testosterone creams and gels that are being used for testosterone replacement therapy for both women and men. These are being compounded by pharmacies according to a doctor's prescription. The logical caveats are that the cream application should probably be applied two (or even three) times per day, starting first thing in the morning to mimic the rise in testosterone that occurs naturally. While placing a testosterone cream or gel on an area of skin that contains fat will slow the release of the testosterone somewhat, the duration of testosterone activity once it gets into the bloodstream is rather short. After a few weeks of twice daily application, a relatively steady state blood testosterone level is generally attained. Once a day application may result in only short term improved blood testosterone levels, so the person would feel a decline in energy several hours later in the day. Also, the usually recommendation is that it is best to rotate the sites of application around the body, so that optimal absorption is maintained. The best application areas include the inner elbows, under the chin and on the neck, the stomach, the inner thighs, and breasts or pectorals. Unimed Pharmaceuticals will be bringing a testosterone gel for men to the US market soon. The creams and gels are currently available from compounding pharmacies like Womens’ International Pharmacy (1-800-279-5708) and College Pharmacy (800-575-7776).
Testosterone Injections - Women
While we have had some positive feedback about the creams and gels, we have also had women say that they felt little improvement until they were given weekly testosterone enanthate or cypionate injections. The dosage range for effectiveness and safety we have seen for injections has been from as little as 2.5 mg. per week to 20 mg. per week. A first tell-tale sign that the dose is too high is acne and oily skin. If the dose isn't reduced immediately when these symptoms appear, then virilizing effects like dark peach fuzz, or itching and growth of the clitoris may result. It is best to start at a low dose, like 2.5 mg., and check the patients' subjective evaluation of themselves, also testing free testosterone two days after the fourth weekly injection. Increase incrementally and retest as necessary if more is needed.
Cycling For People With Healthy Testosterone Function
Generally speaking, a minority of people who suffer from wasting have healthy testosterone function. Cycling may be appropriate for these people because cycling reduces long-term inhibition of the feedback loop that controls testosterone production in the body. Cycling at the doses and durations in this protocol allows the body time to resume its normal testosterone production after the cycle is ended. Additionally, there is reason to believe that the body loses some sensitivity to the anabolic effects of the steroids when it is "flooded" with high doses of steroids over a long period of time. These are two of the reasons that we advocate anabolic steroid cycles of about twelve weeks, with breaks between cycles of a minimum of sixteen weeks for those people whose bodies can produce healthy levels of their own natural testosterone. We suggest that breaks be as long as possible. Note that Dr. Shalender Bhasin of UCLA, confirms that it took no more than four months for HIV-negative healthy men to return to normal testosterone production after his 600 mg./week, 10 week testosterone enanthate study. 72 He also says that the return to normal took no more than six months for the healthy men in his male contraceptive study that employed 200 mg. per week of testosterone enanthate for one year. While long-term very high dose steroid or testosterone abuse could elicit a more negative result and take even longer to return to normal, Dr. Bhasin's data suggests that the body will
resume its natural testosterone production after the use of the medically sound and reasonable steroid doses in this protocol. Whether this is true for HIV-positive men is not known, however.