Author: noorali

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Low Testosterone in Aging Men

Joggers near the Washington Monument, an obelisk at the National Mall in Washington, DC. (Dr. Noorali Bharwani)
Joggers near the Washington Monument, an obelisk at the National Mall in Washington, DC. (Dr. Noorali Bharwani)

After the age of 40, testosterone levels in men go down by 1% each year. Testosterone boosts mood, libido and muscle mass. It’s a $2 billion industry in the US, with millions of men buying testosterone gel, pills or getting injections.

Clinically, there is only one indication for prescribing testosterone. A man suffering from hypogonadism. Examples of this include failure of the testicles to produce testosterone because of genetic problems, or damage to the testicles from chemotherapy or infection.

Hypogonadism is a medical term for a defect of the reproductive system resulting in loss of function of the gonads. In men, it is the testes. The testicles have two functions: to produce hormones (testosterone) and to produce sperm.

Many men have been prescribed testosterone to boost sexual performance. A blood test will tell when testosterone is low. But doctors do not know what is a normal level for that individual or when the individual is getting too much testosterone.

The concern is that high testosterone level can cause heart attacks. Recently, the Food and Drug Administration (FDA) in the US has stepped up warnings for testosterone and other steroid drug prescribers and users. Testosterone is approved to treat men with medically diagnosed low levels of testosterone. The FDA does not approve the use of testosterone to treat the effects of aging.

The FDA says, “Not only can the drugs cause heart attacks, personality changes and infertility, but people can easily abuse them.”

There is a long list of reported serious adverse side effects including heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity, kidney failure, baldness and male infertility from shrinking testicles.

Individuals abusing testosterone have also reported withdrawal symptoms, such as depression, fatigue, irritability, loss of appetite, decreased libido and insomnia. It can also raise the risk of blood clots.

An article “Predicting low testosterone in aging men: a systematic review,” by Adam C. Millar and colleagues published in the Canadian Medical Association Journal (CMAJ June 20, 2016) says in men over 40, clinical signs and symptoms thought to be associated with low testosterone correlate poorly with testosterone levels.

Miller and his colleagues conducted a systematic review to estimate the accuracy of clinical symptoms and signs for predicting low testosterone among aging men. They found among 6053 articles identified, 40 met the inclusion criteria. The prevalence of low testosterone ranged between two per cent and 77 per cent. Threshold testosterone levels used for reference standards also varied substantially.

Authors of the CMAJ article found weak correlation between signs, symptoms and testosterone levels.

CMAJ editor’s comment: Until we know more about hypogonadism in older men, it’s prudent to be cautious in making the diagnosis and initiating treatment in this group.

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Four Factors that Determine Successful Aging

A windsurfer in Antigua. (Dr. Noorali Bharwani)
A windsurfer in Antigua. (Dr. Noorali Bharwani)

“Everyone wants to age successfully; however, the definition and criteria of successful aging remain vague,” says an article in Gerontologist (Feb 2015).

American Journal of Preventive Medicine (April 2005) looked at eight studies published between 1985 and 2003 that reported statistical associations between baseline determinants and healthy aging outcome.

Six behavioral determinants were found to make a positive difference in a person’s life. These were: smoking status, physical activity level, body mass index, diet, alcohol use, and health practices.

In an article published in the Canadian Medical Association Journal (CMAJ December 11, 2012) by Séverine Sabia and associates looked at the influence of individual and combined healthy behaviours on successful aging.

They concluded that although individual healthy behaviours are moderately associated with successful aging, their combined impact is substantial. In fact they saw clear evidence of the importance of healthy behaviours for successful aging.

It is estimated by 2031, more than 20 per cent of Canadians will be senior citizens. These seniors will have chronic pain, serious age-related diseases and disability. This will cripple our health care system.

It is not too late to advise our patients to pursue healthy lifestyle. In the U.K. Sabia and colleagues carried out an observational study. Participants were 10,308 men and women aged 35 to 55 years.

Successful aging was defined as being alive at 60 years of age and beyond; having no history of coronary artery disease, cancer, stroke or diabetes. These individuals have good cognitive, physical, respiratory and cardiovascular function without disability, and good mental health.

Difficulty of doing a study like this is that there is no consensus definition for successful aging. Sabia and colleagues assessed whether engaging in four healthy behaviours during midlife influences a person’s ability to age successfully. These are:

  1. Regular physical activity
  2. Consuming fruits and vegetables daily
  3. Drinking alcohol moderately
  4. Never smoking

Moderate alcohol consumption and not smoking have well-known health benefits. But the apparent benefits of physical activity and healthy diets, which were not always evident in previous studies, were impressive, says the article.

There was a relatively large beneficial effect from physical activity (≥ 2.5 hours/week of moderate activity, or ≥ 1 hour/week of vigorous activity), which supports the notion that even small amounts of regular activity may have important health effects.

Similarly, although the number of fruits and vegetables to be eaten daily was not quantified, consumption of at least some amount each day appears to have an important association with successful aging. It would be interesting to know whether more servings of fruits and vegetables has a stronger effect and whether there is a dose–response relation, says the article.

To summarize: Sabia and colleagues found that four behaviours increase the odds of living in good health beyond 60 years of age: regular physical activity, eating fruits and vegetables daily, drinking alcohol moderately and never smoking.

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Pragmatic Approach to Treating Inflamed Nasal Passages and Sinuses

Alberta countryside. (Dr. Noorali Bharwani)
Alberta countryside. (Dr. Noorali Bharwani)

Sinusitis refers to inflammation of a sinus, while rhinitis is inflammation of the nasal passage. Anatomical closeness of the sinus cavities and the nasal passages lead to frequent simultaneous involvement of both structures. When both structures are involved the diagnosis is rhinosinusitis. The inflammation may be due to a virus or bacteria. The disease can be acute or chronic.

Rhinosinusitis is a frequently occurring disease. It has a big impact on the quality of life and health care spending. This also affects absenteeism and productivity. It is estimated that approximately six billion dollars is spent on 25 million individuals in the United States annually on therapy for rhinosinusitis. Rhinosinusitis probably affects more than 25 million Americans and 2.5 million Canadians.

As we know the quality of life of patients with chronic or recurrent sinusitis can be unpleasant. Antibiotics are prescribed for nearly all patients with sinusitis, but they are not always effective and increase the risk of antibiotic resistance.

A study published in the Canadian Medical Association Journal (CMAJ September 2, 2016) looks at the pragmatic approach to treating rhinosinusitis. The study involved adults age 18 to 65 years old with a history of chronic or recurrent sinusitis from 72 primary care practices in the United Kingdom. These individuals reported that the illness impacted their quality of life. They were randomly assigned to one of four strategies: usual care, daily nasal saline irrigation, daily steam inhalation, or combined treatment with both interventions. They were followed for three to six months.

The study concluded:

  1. Nasal irrigation: Nasal irrigation for chronic or recurrent symptoms was less effective than prior evidence suggested, but it resulted in reduced overall symptom burden, headache, use of over-the-counter medications and the perceived need to consult primary care physicians in future episodes.
  2. Steam inhalation: Steam inhalation had no consistent benefits. On a personal note – I have found steam inhalation done twice a day does provide temporary symptomatic relief by unblocking the nasal passages. You can try it. It may help but it will not hurt.

The common cold can lead to rhinosinusitis. Common cold is caused by a virus (rhinovirus), and in most cases the severity of symptoms peak by day three. However, the same virus can activate an inflammatory process leading to bronchitis, pharyngitis, and rhinosinusitis.

Rhinosinusitis caused by bacteria usually gets better in less than four weeks. Within this 4-week period, symptoms resolve either spontaneously or with appropriate treatment. There may be up to three episodes per year and full recovery in between episodes.

Harvard researchers found that sinusitis sufferers reported the highest levels of pain and the lowest levels of social functioning, as well as significant problems with work, energy, and mental health.

Mayo Clinic website says, “One of the simplest, cheapest, and most effective ways to prevent and treat sinus problems is nasal irrigation. Using a homemade solution, you can often relieve sinusitis symptoms, reduce reliance on nasal sprays and antibiotics, and improve your quality of life.”

Hope this information helps. Flu season is coming. Do not forget your flu shot!

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Detecting Breast Cancer in Women with Dense Breasts Made Easier

Valley of the Kings, located on the west bank of the Nile, Egypt. (Dr. Noorali Bharwani)
Valley of the Kings, located on the west bank of the Nile, Egypt. (Dr. Noorali Bharwani)

The Canadian Cancer Society recommends that all women 50 to 69 years of age be screened for breast cancer every two years, using mammography. But mammography is less useful in identifying cancerous tissue in women with dense breasts; that is, women whose breasts have less fatty tissue but have more fibrous tissue.

In Canada, more than one million women (that is 50 per cent of women) who are 50 to 69 years old have dense breasts. Mammography is not a good test for picking up breast cancer in women with dense breasts. These women are being offered an additional test in the U.S. at a cost of about U.S. $2000 (two thousand). This test is called molecular breast imaging (MBI). This is not the first line of investigation for breast lumps. All women who are eligible for breast screening first undergo mammography and if necessary ultrasound to see if a lump is solid or cystic. Women with dense breasts then can be offered MBI if the mammogram is negative.

In a study from Mayo Clinic, 2600 women with dense breasts underwent mammogram and then MBI. Thirty two per cent of women were found to have breast cancer. Of these only eight breast cancers were picked-up by mammogram alone but 29 breast cancers were picked up by mammography plus MBI. This test is four times better than mammogram alone, is less painful and gives better pictures. However, this is not the final answer. More research is in progress to see how the results can be improved.

MBI is not going to replace mammography. Mammograms will remain the gold standard in breast cancer screening and will continue to be the standard first step in breast cancer detection. Use of MBI, MRI (magnetic resonance imaging) and ultrasound will continue to serve special populations of patients who need tests beyond a mammography.

Breast MRI is not recommended as a screening tool for women who are at average risk of developing breast cancer. It is better than mammogram but a major disadvantage is that breast MRI screening results in more false positives. In other words, the test finds something that initially looks suspicious but turns out not to be cancer. To avoid unnecessary biopsies MRI screening is reserved for high-risk women only. MRI is also more expensive and not widely available.

In conclusion, mammograms are probably the most important tool doctors have, not only to screen for breast cancer, but also to diagnose, evaluate, and follow people who’ve had breast cancer. It is safe and reasonably accurate. The technique has been in use for more than 50 years. MBI is still being tested, but it appears to hold promise for detecting breast cancer in women who are at higher-than-average risk for the disease and have dense breasts. Ultrasound and MRI is used for special cases.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!