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    Alternatives to T therapy: Lessons from male infertility

    Choice of three agents allows most men to transition from testosterone to alternative therapy

    James M. Hotaling, MD, MS William O. Brant, MD Steven A. Kaplan, MD

    James M. Hotaling, MD, MS

    William O. Brant, MD

    Section Editor Steven A. Kaplan, MD

    Testosterone use in the United States is currently rising at unprecedented levels. Annual testosterone prescriptions have increased more than fivefold from 2000 to 2011, resulting in $1.6 billion in revenue and 5.3 million testosterone prescriptions in 2011 alone (FDA Bone, Reproductive and Urologic Drugs Advisory Committee [www.fda.gov]; Nature Rev Endocrinol 2013; 9:414-24). Perhaps the best evidence of the success of testosterone therapy has been the recent Time cover article on “manopause” and the fact that the marketing campaign for “low T” is now taught at Harvard Business School as an example of the most successful marketing campaign in the history of medicine.

    RELATED: Men’s health: The argument for a holistic approach

    All of this has meant that urologists are now more than ever on the front lines of men’s health. Both the desire to preserve the youthfulness of an aging baby boomer population and a younger population seeking a competitive edge in the work force—and in play—drive our patients to seek treatment. Or, perhaps, as Albert Einstein said, “Even our destiny is determined by the endocrine glands,” and men are just becoming aware of this.

    Whatever the exact mechanism of the increase in desire for testosterone replacement therapy in men, knowing the risks and benefits of testosterone and its alternatives are vital skills for today’s practicing urologist. This article will focus on alternatives to testosterone therapy.

    Why alternatives to T?

    Male infertility specialists frequently manipulate the hypothalamic-pituitary-gonadal (HPG) axis in order to treat primary endocrine derangements or counteract the deleterious impact of exogenous testosterone on spermatogenesis (Urol Clin North Am 2014; 41:39-53). In order to appropriately manage hypoandrogenism, it is necessary to understand the HPG axis and the risks and benefits of the off-label use of female fertility agents in men (figure 1).

    Next: Impact of age on testosterone

    HPG axis and sites of action and treatment

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