Category: Medicine Hat News

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Treating Men with Testosterone Deficiency can be Challenging

Statue of Abraham Lincoln at the Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)
Statue of Abraham Lincoln at the Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)

Testicles produce a hormone called testosterone that plays an important role in the masculine growth and development during puberty. Testosterone also plays an important role in the production of sperms. Poor testicular function results in erectile dysfunction (impotence). There is a failure to get and maintain an erection firm enough for sex.

Testosterone deficiency syndrome (i.e. poor testicular function) affects approximately 40 per cent of men aged 45 or older, although less than five per cent of these men are actually diagnosed and treated for the condition. It may affect multiple organ systems and can result in substantial health consequences for men.

Despite some controversy, testosterone therapy has been established as a safe and effective principal treatment for poor testicular function for nearly 70 years. But there is no consensus among experts on how and when to treat men with this condition.

A recent article in the Canadian Medical Association Journal (CMAJ December 8, 2015) welcomes the new Canadian guideline from the Canadian Men’s Health Foundation. It is hoped that the new guideline will clarify the management of this condition in the light of the huge volume of research on this topic over the last five years.

In the past there have been multiple guidelines from different groups like European Association of Urology, the International Society for Sexual Medicine, the International Society for the Study of the Aging Male (2008), and the Endocrine Society guidelines of 2010.

One cannot treat a condition if it is difficult to make a diagnosis. The diagnosis of testosterone deficiency syndrome is not straightforward, says the CMAJ article. The reasons are several. There are limitations to testosterone measurement and there is lack of a valid symptom score. This makes it difficult for the primary care physicians to make a diagnosis and start treatment. Especially when the experts cannot agree on values (normal vs. abnormal blood levels of testosterone).

The new guidelines do not define normal/abnormal blood levels for making a diagnosis of testosterone deficiency syndrome. Instead, the authors put weight on a combination of factors – clinical history, physical examination and response to therapy – in making the diagnosis, in addition to measuring testosterone level.

The European Association of Urology and the International Society for Sexual Medicine set parameters that men with a total testosterone level of less than 8 nmol/L will usually benefit from treatment. A trial of therapy may be indicated for those with levels between eight and 12 nmol/L in the presence of substantial symptoms.

There is no consensus on how long the initial trial of testosterone should last. The Canadian guideline advises a three-month trial of treatment. Some experts disagree with that. They suggest the trial should last six-months to 12-months.

Some other points of interest:

  • More than three-quarters of men with type 2 diabetes have erectile dysfunction, and about 90 per cent have positive symptom scores for testosterone deficiency syndrome.
  • Injection of testosterone, especially long-acting formulations, has higher efficacy rates and safety benefits than topical treatment. Other options are gels, patches or oral pills.
  • Opinion varies on monitoring patients taking testosterone therapy e.g. checking effects of testosterone on prostate (PSA).

It is important to remember that many important clinical issues remain unresolved. This article is just a summary of important points. The reader is advised to consult with his physician for more information.

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Herbal remedies and vitamin supplements can be good, bad and ugly.

Cloud Gate, nicknamed The Bean, in Millenium Park, Chicago. (Dr. Noorali Bharwani)
Cloud Gate, nicknamed The Bean, in Millenium Park, Chicago. (Dr. Noorali Bharwani)

Recent CBC investigation report (Fifth Estate) revealed that herbal remedies and vitamins are frequently approved for sale in Canada with only minimal review. Even Health Canada acknowledges that their approval of these products is based on “weak evidence,” says the CBC report. That indeed is shocking.

The CBC report indicates that Health Canada approves more than 90 per cent of applications to sell new natural health products. And under updated rules, products can be approved in as little as 10 days.

Are we fully aware of the quality and safety of many of these supplements? The answer is no. We don’t. U.S. statistics show supplements send 23,000 people to hospital each year. Annual sales in Canada total about $1.4 billion, and Health Canada’s Natural and Non-Prescription Health Products directorate must approve supplements before they go on sale.

According to the CBC report, some leading researchers also say there is mounting evidence that many of the most popular supplements don’t live up to their claims and could even be dangerous. Common complaints about these products included contamination, purposeful adulteration, incorrect strength and incorrect identity.

Medically speaking a healthy individual, who eats a good diet, does not require vitamin supplements. But almost 30 percent of our population does not follow that dictum.

On the other hand, there is a consensus among medical experts that taking certain vitamin supplements on a daily basis does more good than harm.

Here are some examples:

  1. Folic acid (400 ug/day) reduces the risk of birth defects during pregnancy.
  2. Multivitamin tablet – one a day. Vitamin B such as B6 and B12, may help lower blood levels of a substance called homocysteine that may help reduce the risk of heart disease and stroke.
  3. Vitamin D (1000 – 2000 IU/day) minimizes the risk of osteoporosis and fractures and colon and breast cancer.
  4. Omega-3 fatty acids – 1000 mg/day or eat fish three times a week. This reduces the risk of sudden heart attack by 50 to 80 per cent. It can help ward off the serious heart rhythm disturbances associated with sudden cardiac death. It also appears to reduce the risk of strokes, mental decline in old age and prostate cancer.

In summary, one multivitamin, vitamin D and omega-3 should cover what you need if you are otherwise healthy. Remember, this is just a guideline. Discuss with your family doctor before you start these pills. If you opt to use herbal remedies for prevention or treatment of an illness check whether there is any science associated with the recommendation.

Vitamin supplement is just an icing on the cake – so to speak. Too much of icing and/or too much of cake is not good for your health!

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Auto-brewery syndrome – a rare condition where the body brews its own alcohol.

"Looking Into My Dreams, Awilda," is one of four large-scale portrait sculptures titled "Jamue Plensa: 1004 Portraits," in Millennium Park, Chicago. (Dr. Noorali Bharwani)
"Looking Into My Dreams, Awilda," is one of four large-scale portrait sculptures titled "Jamue Plensa: 1004 Portraits," in Millennium Park, Chicago. (Dr. Noorali Bharwani)

It was reported on CNN and now it is making rounds in the media. A woman in upstate New York was charged with DUI (driving under the influence) hours after her last drink.

The lady blew a blood alcohol level of nearly 0.40. The police procedure is to take the accused to a hospital, as that level is considered extremely life threatening.
The lady’s blood alcohol level in the hospital was 0.30. This was many hours after her last drink.

The lady was charged with DUI but a judge dismissed the charge after being presented with evidence the woman suffered from “auto-brewery syndrome.”

“I’m in touch with about 30 people who believe they have this same syndrome, about 10 of them are diagnosed with it,” says Panola College Dean of Nursing Barbara Cordell, who has studied the syndrome for years. “They can function at alcohol levels such as 0.30 and 0.40 when the average person would be comatose or dying. Part of the mystery of this syndrome is how they can have these extremely high levels and still be walking around and talking.” Cordell was quoted on CNN.

The condition is also known as gut-fermentation syndrome. This rare medical condition can occur when abnormal amounts of yeast in the gut convert common food carbohydrates into alcohol. The process is believed to take place in the small bowel.

The condition was first described in 1912 as “germ carbohydrate fermentation.” Since then, from time to time, it has surfaced in the media. In 2013, a case of a 61-year-old man who had frequent bouts of unexplained drunkenness for years was documented. Subsequently, he was diagnosed with an intestinal overabundance of Saccharomyces cerevisiae, or brewer’s yeast, the same yeast used to make beer.

CNN report says that the lady is treating her condition with anti-fungal medications and a yeast-free diet with absolutely no sugar, no alcohol and very low carbs. The report says that this does not work for everybody.

So I looked it up on Wikipedia.

The condition has been described variously. The self-brewery syndrome, intestinal fermentation syndrome, and gut syndrome fermentation is an intestinal disease and very poorly documented. There is no consensus among specialists.

The condition was described for the first time in 1976 in Japan. One case went unnoticed for 20 years, despite strong alcoholic intoxication following meals high in sugar or high in carbohydrates.

Symptoms of the disease can have a significant impact on daily life, says Wikipedia.  Recurrent symptoms such as dizziness, dry mouth, cold sweats, hangover, disorientation, irritable bowel syndrome, chronic fatigue syndrome, which can lead to other health problems such as depression and anxiety.

Is there a good treatment for it?

In general, the effects of the condition can be alleviated with a very low carbohydrate diet. The antifungal drug, fluconazole, can be an effective treatment against the disease since the drug is able to reduce Saccharomyces cerevisiae, responsible for fermentation in the gastrointestinal tract.

If you think you are suffering from auto-brewery syndrome, then to put it simply, don’t eat and drive.

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

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In 2016 follow eight steps to wellness and be healthy and happy.

Kin Coulee Park, Medicine Hat. (Dr. Noorali Bharwani)
Kin Coulee Park, Medicine Hat. (Dr. Noorali Bharwani)

“There is only one happiness in this life, to love and be loved,” says George Sand, a pseudo name for a female French novelist. I guess she was happy to be a woman and use a man’s name.

It is important to be in love and be loved. It is also important to be healthy.

Those who are familiar with my columns and my books will know that I espouse eight steps of wellness for long-term good health and happiness. These are: healthy eating, no smoking, regular exercise, stress relief, adequate sleep, sexual empowerment, laughter and meditation.

Generally speaking, the most common desire is to lose weight. Sixty per cent of the people are overweight. We know why one should not be overweight. We know what one should do to lose weight. But the problem is how to implement the plan that will make us lose weight. A simple plan is to lose one pound a week. Can you imagine if you lose one pound a week, you can lose 52 pounds a year? That is amazing. Slow and steady wins the race. Rome wasn’t built in a day. OK you get the point.

Don’t just give up on eating. Be a smart eater. Make sure a healthy eating plan is one that has fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products. Include lean meats, poultry, fish, bean, eggs, and nuts. And is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars. Isn’t that easy?

Eating smart (not dieting or starving) is one step in the grand design to be healthy. The second step is regular exercise. Again you don’t have to have a grand plan to join a club or run a marathon if you have children and a busy life. On a good day you just have to go outside your house and walk for 30 to 40 minutes a day. If the weather is bad then go to the mall and walk for half-an-hour and do window-shopping. That is not difficult. If you do that five days a week then you have burnt enough calories to lose some weight. It will also make you feel healthier and happier with no sense of guilt.

Smart eating and regular walking should not be difficult. If you are a smoker then you can quit on your own or seek help. Neither option is easy to implement. There is some success and lot of failures due to the addictive nature of nicotine. But success can be achieved if you have the determination. If you are serious about quitting then seek help. That would be the smart way to go. Talk to your family doctor.

The next five steps are important too – stress relief, good sleep, sexual empowerment, laughter and meditation. These five steps are more mental than physical. You need to devote more time and mental discipline to achieve your goals. You can read more about it in my previous columns or my books.

I have tried to keep this column short and to the point. This is busy time of the year. Make sure you spend lot of time with your family. Do not drink and drive. Be happy and relax so you can charge your batteries for 2016.

I wish you and your family a Happy New Year and may you all be blessed with peace, good health and happiness.

Have fun but be safe.

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