2022 Archives

Testosterone as a Fasting Blood Test?

Posted by Martin M. Miner, MD | Jan 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, discuss recent guidance suggesting that a fasting blood test is needed for testosterone. Dr. Moyad begins by explaining that in 2018, the Endocrine Society Clinical Practice Guidelines included a recommendation of measuring fasting morning testosterone. He suggests that this is a logical recommendation since, in a subset of men, testosterone levels may be temporarily lowered by food intake, but notes that this guidance does not appear to be widely known or followed. Dr. Miner says that he actually does usually include testosterone with other morning fasting tests to meet the demands of insurance, although he argues that this may also result in inaccurate levels since testosterone is supposedly at its peak in the afternoon. He also mentions that the American Urological Association does not recommend getting testosterone tested in a fasting specimen, although he is unsure why this is. Dr. Moyad concludes that this is a topic that is just beginning to be explored and should be watched.

Testosterone, Weight Loss / Weight Gain, and Testosterone Replacement Therapy (TRT)

Posted by Martin M. Miner, MD | Jan 2022

Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, and Martin M. Miner, MD, Co-Director of the Men’s Health Center and Chief of Family and Community Medicine for Miriam Hospital, and Clinical Professor of Family Medicine and Urology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, investigate the ways in which body mass index (BMI) correlates with testosterone levels and how this knowledge can be used in a medical setting. Dr. Moyad begins the discussion with Dr. Miner’s presentation on the possibility of testosterone needs increasing as BMI increases, wherein Dr. Miner found that obese men required higher doses of testosterone to reach eugonadal levels than men who were not obese. Dr. Miner states that he expects the results of a long-term safety study of testosterone will soon show that testosterone therapy is safe over the long term, allowing physicians and researchers to focus on the symptomatic benefit of testosterone in areas such as mood and cardiovascular risk. Dr. Moyad asks if weight loss and increased fitness could possibly reduce the need for testosterone therapy, to which Dr. Miner responds that it may be possible if both weight loss and a reduction in comorbidities occur but it is unlikely in patients over 60. They conclude that weight loss can help make testosterone therapy more effective but it is unclear if it would be enough to reduce testosterone therapy altogether because of a multitude of genetic variables.

PCa Commentary | Volume 161 – January 2022

Posted by Edward Weber, MD | Jan 2022

This Commentary looks at bipolar androgen therapy (BAT) as a treatment option for metastatic castration-resistant prostate cancer (mCRPC).

Saw Palmetto and BPH – Past, Present, and Future

Posted by J. Curtis Nickel, MD, FRCSC | Jan 2022

After an introduction from E. David Crawford, MD, Professor of Urology at the University of California, San Diego, and Editor-in Chief of Grand Rounds in Urology, Mark A. Moyad, MD, MPH, the Jenkins/Pokempner Director of Preventive/Complementary and Alternative Medicine (CAM) at the University of Michigan Medical Center in the Department of Urology in Ann Arbor, Michigan, interviews J. Curtis Nickel, MD, FRCSC, the Canada Research Chair in Urologic Pain and Inflammation and Professor of Urology at Queen’s University in Kingston, Ontario, on the history of the herbal medicine saw palmetto and its efficacy as alternative medicine for benign prostatic hyperplasia (BPH). Dr. Moyad observes that in the early 2000s, saw palmetto was widely discussed in North America, but seems to have disappeared from the conversation in recent years. Dr. Nickel explains that while this is true, saw palmetto continues to be developed as a treatment option in Europe. He then notes that the STEP and CAMUS trials were some of the main contributors to North American loss of interest. The 2006 STEP trial failed to prove that saw palmetto had greater efficacy than placebo in BPH by North American medical standards, which Dr. Nickel believes was due to there being different forms and sources of saw palmetto extract and it being difficult to control for which would be used in a study at the time in North America. Dr. Moyad highlights that while this trial may not have found a benefit to saw palmetto, it also found it to be as safe as placebo. Dr. Nickel then goes into further detail about the CAMUS trial, which he worked on, and which was initially based heavily on European studies. However, due to the negative results of the STEP trial, CAMUS was redesigned, and ultimately it too found little difference between saw palmetto and placebo. Dr. Nickel notes that he feels that he and his fellow researchers may have missed something critical in that trial, and ponders why the two North American studies had negative results while so many other trials had positive ones. He also notes that he continues to recommend saw palmetto as an adjunct therapy to many of his patients based on the international literature. Drs. Moyad and Nickel then discuss some of the sourcing difficulties related to saw palmetto, as well as different extraction methods. Dr. Moyad then references Permixon, a European medicinal product derived from saw palmetto, and Dr. Nickel discusses how the way that it is regulated and processed differs from how saw palmetto is handled in North America. Dr. Nickel clarifies that he thinks that saw palmetto is a good alternative treatment for BPH patients looking for less invasive disease management options as long as a USP (US Pharmacopeial Convention)-approved product that is analyzed thoroughly is used.

Active Surveillance – When Can You Continue Watching and When Do You Intervene?

Posted by Dov Kadmon, MD | Jan 2022

Guilherme Godoy, MD, MPH, Assistant Professor of Urology and Urology Oncology, Dov Kadmon, MD, Professor of Urology, and Michael A. Brooks, MD, Assistant Professor of Urology and Oncology, all at Baylor College of Medicine in Houston, Texas, discuss active surveillance (AS) for prostate cancer by using numerous case studies outlining patient characteristics, evaluation methods and diagnosis, the discussion and decision-making process, treatment, and outcome data to illustrate best practices. Their panel discussion covers magnetic resonance imaging (MRI)-fusion biopsy and systematic biopsy and highlights the need to use both as they are complementary. The doctors also discuss risk-benefit analysis; the role of urine, blood, and genomic testing; treatment algorithms, and important considerations such as those surrounding the patient’s overall health and life expectancy. Dr. Kadmon highlights the importance of integrating experience, common sense, and research. He emphasizes that integrating prostate MRI in AS protocol is imperative and MRI is important both when starting AS and in follow up. The doctors caution that MRI is not infallible; if the follow-up MRI is negative but there is strong suspicion for progression, a regular follow-up biopsy is justified. They advise that these follow-up biopsies be done for a reason and not just not based on an arbitrary time interval. Dr. Kadmon reiterates the point that a fusion biopsy and a systematic biopsy are complementary and should be carried out simultaneously and concludes by reviewing success elements involved in prostate MRI, including the equipment and protocols used, the experience of the radiologist, and whether the radiology program includes a quality improvement feedback loop, emphasizing that all these factors are important.