Be nice to have Superman's hair…but at what price? (Courtesy; MovieBlog.com)

It’s the perfect drug for 40 million men in America who are going bald. Take it once a day to keep the hair on your head and shrink the prostate, which also commonly bothers men as they age. It’s a pill that has been used by at least 2 million reproductive age men over the last decade. But is it too good to be true?

The Best Hair Pill Yet

This magic pill is finasteride (trade names; Propecia, Proscar, Avodart). It represents a class of drug called the 5-alpha reductase inhibitors. These pills act as enzyme blockers: they prevent the male hormone testosterone from converting to its metabolite dihydrotestosterone (DHT). Although testosterone is responsible for a lot of our “male” features, DHT is more potent than testosterone for scalp hair and our internal reproductive organs (prostate, seminal vesicle). These drugs work by lowering DHT production and protect the gloriously youthful hair on our heads and the enviable ability to write your name in the snow while urinating.

And these drugs work well. More effective than topical or “rub in” medications, finasteride is great for what’s called “male pattern” hair loss which is due to a receding hairline or balding on the top of the head. In essence, it slows the growth phase of hair in these areas. However, it doesn’t treat hair loss on the sides or temple area.

Finasteride, Sex and Male Fertility

Although it may keep you looking like Clark Kent, many male infertility specialists, including myself, have concerns about finasteride. First, there is a 10% chance of sexual side effects that include erectile and ejaculatory dysfunction and lowering of sex drive. These issues can be subtle while on the pill but become very obvious when men stop it; many of my patients have noted a sexual “curtain being lifted” or “coming alive” after discontinuing the pill.

Second, there is an even more profound concern about finasteride among specialists: male infertility. Before it received FDA approval, the drug trials showed that it lowered ejaculate volume but did not change sperm count or motility on semen analysis testing (actual human fertility studies are not routinely required by the FDA). Now that it has been on the market for 10 years, though, impressive declines in semen quality have been observed and published with finasteride by many of us. This effect is not subtle either, as patients with complete sterility (azoospermia) have had recovery of their sperm counts after stopping finasteride!

There are several clues that this effect on fertility was possible. The rabbit studies done for FDA approval of the drug actually showed this effect. At 3 months, there was no effect on rabbit fertility. But, when followed longer, rabbits showed significant decreases in natural fertility. In addition, while I was writing a recent reproductive physiology chapter for Campbell-Walsh Urology, our leading urology textbook, I researched at what levels the 5-alpha reductase enzyme is found in the human testis and epididymis. Lo and behold, there are gobs of this enzyme in these important organs for sperm production and maturation, implying that the blocking agent finasteride would have an effect. So now what do we do?

At this point, controlled clinical trials are needed to prove this effect on fertility. For the time being, current thinking is that finasteride may not dramatically change sperm production in healthy men, but can impair semen quality in infertile men. Typically, the effects of medications on male infertility are reversible. So, to be proactive men should consider stopping the pill at least 6 months prior to trying to conceive. And, have confidence that she loves you just as much for other reasons. As Telly Savalas once said: “We’re all born bald, baby!”

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Why Urology?

Admittedly, urology is a small, unusual and low-key medical specialty. In fact, for the longest time, my parents didn’t know exactly what I did as a doctor. I kind of like that about it. Feel free to choose a more glamorous, chest pounding, field like neurosurgeon or heart surgery if you like. I’ll stick with urology, thank you. It’s a fantastic balance of medicine and surgery, and involves the care of both adults and kids and men and women. All you have to do is get through six years of surgical training after medical school to join the crowd!

Spreading the Word

Since my time as a decorated professor at UCSF, I have been committed to getting students interested in our little corner of the medical world. This effort has resulted in the publication of a national curriculum for teaching urology to U.S. medical students now hosted on our leading society’s website. As popular as it has become, it is really an essential national resource for the field of urology as it slowly gets squeezed out of the tight, full schedules of medical students nationwide. For some reason, pharmacogenomics now matters more than prostate cancer in medical school.

Even with this under my belt, I felt that more was needed to get students turned on to our specialty. We needed to hear from real life urologists, both those in training and at the top of their game, and see why they chose this field. The field is ripe with superb mentors and I wanted to show them off. So, with the help of our national society, we recently created a short video in which urologists talk about why they chose this field. Well, “Why Urology?” has certainly hit the ground running,  and just garnered a national marketing award in its first several months of life!

Love what you do, make a difference doing it and spread the word. These are the tenets of my life in medicine.

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Is the Internet the true, universal soul of man and woman?

Here it goes again. Doctors are out of a job because of _____ (fill in the blank with antisepsis, antibiotics, vitamins, lasers, robots, etc). Now, it’s the Internet.

A recent newspaper article discussed that 60% of Americans and 70-90% of Europeans now seek health information online. Especially impressive is the number of older individuals, or “silver surfers” that find themselves there looking for help. With this powerful informational tool in their hands, the article raised the issue of whether empowered patients will make doctors extinct.

After reading the article, I wrote an Op-Ed piece to the paper, but never saw it published. Just to get it off my chest, I present it here:

Sir, Ms. Bird has absolutely hit the nail on the head when discussing the fact that today’s patients are truly educated consumers. In my men’s health practice, I routinely see patients who have the latest published paper on their condition tucked under their arms as they sit in front of me at the visit. Kudos to them! I am delighted that patients are informed and ready to “own” their healthcare–it is long overdue in the field of men’s health. Patient ownership of their health means that their best advocate (themselves) tags along at every visit like a loyal dog and helps them safely navigate within a super-specialized and highly fragmented health care system.

Although medically empowering, the Internet cannot provide two critical components of quality health care that will ensure the ongoing value of doctors in medicine: knowledge and wisdom.

The Internet is extremely informative but lacks the judgment necessary to distinguish wheat from chaff. Likewise, it lacks experience, the learning that accrues from seeing the same problem a thousand different ways, and a trait fundamental for quality decision-making in any profession.

We as doctors cannot possibly know all there is to know in a profession that doubles in informational size every decade. However, through rigorous training, experience, discipline and focus, we can comfortably tread where even the best-informed patients have not considered, or cannot imagine, going alone.

In fact, medicine owes a great deal to the rise of the information age. Doctors can now “walk the walk” with patients in a truly informed partnership. And patients can better judge the quality and character of their providers as they make life-changing decisions about their health.

Respectfully,

Paul Turek  MD, FACS, FRSM

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A gavel with teeth for this President…

In two days, I will hand over the gavel. It’s actually a meat tenderizer that I bought to run the meetings this year and it worked just great. A gavel with teeth. Regardless, I surrender it with mixed feelings. On one hand, a year as President of one of America’s leading academic societies is a lot of work. On the other, though, I feel like I am just getting started and that the ship is now running fast with sails full. As we all know from politics, systems with rotating leadership all have their virtues and vices.

The American Society of Andrology

The Society that I lead is the American Society of Andrology. It was founded in 1975 and has about 700 members, most of whom are academic researchers. I guess I have a soft spot for nerdy scientists who care about men’s health. Honestly, though, this group is unique. This week’s annual meeting in Montreal brings together a top-notch group of scientists and clinicians from around the world whose expertise, interest, friendship and collegiality lend to a remarkable cross-fertilization of science and medicine.

What the Heck is Andrology?

My mother still asks me this question. Andrology is the study of men’s health and, in particular, the male reproductive system. It involves all aspects of reproductive fitness, including fertility and infertility, erections, hormones and sexuality. As a reflect upon the Society’s position in the academic world, my elevator pitch is that this Society’s focus is on “The Science of Men’s Health.”

President’s Tribute

The year has been a good one: restoring falling membership, bringing financial stability, initiating a strategic plan and an endowment campaign, and brokering the merger of the Society’s academic journal with that of its European counterpart, the European Academy of Andrology, to ensure its future livelihood.

But, as with most endeavors, the people make the party and I must admit, my colleagues rose magnificently to execute the demanding projects that I put forth this year. And this means a whole lot. In fact, this and only this is substance of my final toast, a limerick, at the Welcome reception tonight. I probably shouldn’t leak it here early, but for you dear reader I submit:

There once was a crazy society,
Subscribed to by much notoriety,
Its goal, so sincere,
To study things dear,
Like sex, with the utmost sobriety.

But not only sex does it foster,
There is but a much longer roster:
Like sperm, prostate, erections,
And most epididymal sections,
And diseases like clap and zoster.

And don’t forget contraception,
The inimitable acrosome reaction,
And ejaculation that’s early,
With low libido that’s surely
A sign of hormonal malfunction.

So as we meet here in old Montreal,
Let’s remember these orders so tall:
To discuss, think and debate,
With friends old, new and irate,
The science to which we are called.

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Mirror, mirror on the wall…

They called again and want to talk. Similar to a strict parent who gives you little clue as to where they stand, the National Institutes of Health (NIH) wants to have a conversation. I said: “Yes, absolutely.”

The NIH is nation’s power player in healthcare research. In 2010 it spent $32 billion or about $100 per American citizen forging new research paths, describing and curing disease, informing and transforming health care and keeping academic centers financially afloat. It is a model of healthcare research worldwide.

They want me to lead a think tank session next week in Washington D.C. at the NICHD headquarters. In the dead of winter, they are crystallizing plans to roll out a comprehensive new vision for reproductive health in America. This vision will lead to a white paper statement and guide the government’s research agenda for years to come. I am honored to attend.

Leading a session of experts from around the country, I will guide discussion of how reproductive health is a window to overall health, a topic upon which I have often reflected both here and in the published literature.

In preparation for this innovative meeting, I made a list of all of the medical conditions or illnesses that have been linked to male infertility or erectile dysfunction, either causally or by association. I also included conditions linked to having a past history of either of these sexual health disorders. What frightened me is that the list is 40 conditions long! Everything from diabetes to dyslipidemia, hypertension to heart disease, from tobacco use to sexually transmitted disease, and from chromosomal disorders to cancer. This list is extensive, sobering and reaffirms my deeply held belief that sexual health is a “window” into men’s overall health. Not only do male sexual health disorders coexist with many other medical conditions, but they also predict the future occurrence of even more.

So I will be showing up in Washington with my sleeves rolled up and ready to clean the sullied panes of the looking-glass, and hoping to clarify a new vision of men’s health.

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Is this the dawning of the Age of Aquarius?

It really seems like the moon is in seventh house, and that Jupiter is aligned with Mars. Why? Because our government gets it and want to know how it can help.

Last week, I spoke at a stakeholder meeting about men’s reproductive health, held at the Centers for Disease Control (CDC) in Atlanta. You may have heard of the CDC, begun in 1946, as the American government’s disease surveillance unit. Answering to the executive branch of the government and not to Congress, the CDC has a storied history over the past 60 years, being integral to the worldwide eradication of smallpox and to the control of measles and rubella and more recently, HIV. And who can forget the role that the CDC played in identifying the cause of Legionnaires disease, toxic shock syndrome and SARS? Well now they are interested in men’s reproductive health. You gotta believe.

What’s wrong with men’s reproductive health care in the U.S.? Well, in a sense, it doesn’t exist. Most men who are infertile do not get the care that they should; most male sexual health issues are verboten topics for public discourse; and men’s roles in family life and contraceptive planning are paltry at best.

It warms my heart to know that among all the government branches that could have taken men’s reproductive health seriously, the CDC has picked up the ball. After all, they are interested in assessing populations at-risk and controlling epidemics. And that is exactly the kind of thinking that will improve men’s reproductive health in the U.S., a condition that could certainly be termed an epidemic. A couple of years ago, I wrote an NIH grant (that was funded no less!) to help train male reproductive specialists at UCSF that began with the following sentence: “Men’s reproductive health is a large and underserved area of medicine in the U.S.” Amen.

This first-of-its-kind meeting was brimming with excitement. Attended by non-profits, academics, urologist thought leaders and numerous federal agencies, it was clear that the time had come to rethink the way we take care of young men. The definition of men’s reproductive health that guided the discussion was “the ability to have a responsible, satisfying and safe sex life and the capability to reproduce and the freedom to decide if, when and how often to do so.” In this context, awareness, public health, barriers to care, messaging, resources, engagement, and communication were terms addressed as if this topic were a true, national epidemic. In the words of Wallace Stevens: “Thought is an infection. In the case of certain thoughts, it becomes an epidemic.” For the good of a large chunk of our population, let’s hope that this issue goes viral.

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One strong arm does not a man make…

Testosterone is one misunderstood molecule. It has such great influence over the human body that it has gained a reputation, a mystique. Society associates testosterone with Arnold Schwarzenegger (circa 1980s), with strength, virility, aggression, violence, square jaws and six-pack abs. We also tend to blame it for certain male tendencies and traits in our society, as well as certain medical disorders, although there is little scientific basis for this reasoning.

Testosterone is the major sex steroid hormone in men, and its effects are wide-ranging and powerful. It will make a boy into a man, for one thing. It sparks the development of facial and pubic hair, Adam’s apples, deeper voices, bigger muscles, broader chests. In the adult male, testosterone is necessary for sexual desire, erection maintenance, and sperm production. It also affects other body functions not directly related to sex–important ones–such as maintaining a normal blood count, bone strength, muscle mass and mood.

Testosterone might explain the perpetual sexual desire of a sixteen year-old whose previously unannointed body is now seeing it for the first time, but it does not explain away acts of violence. One popular belief is that excessive testosterone can make one uncontrollably aggressive. However, men actually tend to feel moodier and more anxious with lower testosterone levels, and there are reports that testosterone treatment can disperse these negative feelings. Also, studies show that there is a higher correlation between acts of violence and a past history of violence, than between violence and testosterone levels.

It is also untrue that high testosterone levels cause male pattern baldness and prostate cancer. Baldness is not a sign of virility, and is not associated with high testosterone levels. It is associated with genetics, specifically from the mother’s side of the family (male pattern, crown centered baldness) or the father’s side (overall baldness). Prostate cancer, meanwhile, appears to be associated with low levels of testosterone, and not high ones. So, basically, despite being the cause of hairiness, sweatiness, smelliness, and horniness, testosterone is very good for men.

Does it deserve the bad rap it gets? Taken appropriately, as replacement for naturally low levels, testosterone is not dangerous, nor is it illegal. If taken as a supplement, things are different. Anabolic steroids are synthetically produced variants of natural testosterone. Some common street or slang names for anabolic steroids include arnolds, gym candy, pumpers, roids, stackers, weight trainers, and juice. There are about 100 different types of anabolic steroids circulating nowadays and you will get over 1 million hits on Google by entering “buy steroids,” if you’re interested. When anabolics are taken as a supplement to boost normal testosterone levels, they can lead to some interesting side effects: shooting blanks instead of having a normal sperm count, getting tender breasts when you really don’t want them, and acne like when you were fourteen. Here’s where the bad rap enters the picture. And with steroid abuse, all bets are off regarding the healthy benefits that normal testosterone balance has on cholesterol balance, liver and heart health, blood pressure and mood. So be just like the power hitter Jim Thome, who said: “The strongest thing I put into my body is steak and eggs.”

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Amber waves of grain, the stuff of our Neolithic ancestors

At some point as we evolved, well after the Neolithic period, we started thinking that there must be a better way to get nutrients, something faster and more efficient, than through the food we have eaten for tens of thousands of years. Our fantasy of the future was encapsulated with TV shows like The Jetsons and Star Trek, where roast chickens and earl grey tea were produced by the touch of a button. Nowadays, grocery stores offer fruit smoothies, breakfast bars, energy drinks and microwave pizzas, so we can fuel up quickly and efficiently. Why sit down when you can eat while running? We take vitamins with the idea that we can rectify any potential deficiencies and even prevent illness, with the swallow of a pill. How simple, how easy, how efficient.

As a society, we are in love with “nutriceutical” supplements. About half of all adults take a multivitamin everyday and it is estimated that $75 billion worldwide is spent annually on nutriceuticals. And nonvitamin and nonmineral natural product use is so prevalent in the U.S. (40% of Americans) that the National Institutes of Health has even commissioned a new branch devoted entirely to the pursuit of complementary and alternative medicine research. This effort will undoubtedly unleash the true potential of alternative medicine. But let’s drill down on vitamins for a minute. What does the evidence really show? Well, it appears that taking vitamin supplements may not as beneficial as previously thought. Several major studies have now shown that vitamin supplements do little to prevent cancer and heart disease, while other studies report that vitamins and antioxidant supplements may actually increase cancer rates. One study concluded that folic acid supplements actually increased rates of precancerous colon polyps, and another study linked beta-carotene to higher lung cancer rates. Are vitamins then, failing us as supplements?

No one discounts the necessity of vitamins for our body’s function. Indeed, many diseases are associated with a deficiency in one or another vitamin. But we do place rather high expectations on vitamins. It’s rather narrow-minded of us to tout only a few particular nutrients in food and assign them letters of the alphabet, when many others may be just as essential to our primitive bodies, yet are unfamiliar to us intellectually. Vitamins do not exist in a void, but are part of a complex mixture of substances called food that is the real stuff of life. If anything, the fact that vitamins are getting an F in cancer prevention suggests that the way that they are absorbed in a pill is not the same as the way we extract them from whole foods that we eat.

My patients frequently ask me what supplements they should take to enhance their sexual health or fertility. The truth is that because sexual health is so thoroughly intertwined with overall health, I emphasize a whole-body approach. I don’t recommend a specific course of supplements, but antioxidants may have some value. If they wish to take a supplement, they may, but the important thing is that they get all nutrients necessary for their bodies to function optimally. The real solution to this is a well-balanced diet low in fat and sugar, emphasizing whole grains, fruits, and vegetables. That said, I do realize how resistant many people can be to changing their diet. If a patient feels they must take a supplement to compensate for poor eating habits, I steer them towards whole food supplements that contain a larger and more complex spectrum of nutrients than that found in traditional multivitamins. In all honesty however, I firmly believe in carrots from the earth and apples from trees, just like our Neolithic ancestors did.

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One famous fountain: the mannequin pis in Belgium

As a man ages, he is more likely to look at travel experiences as a series of restroom stops. He might begin navigating his way to the grocery store, the gas station or to a friend’s house for poker based on whether or not there’s a restroom conveniently located nearby. This may sound like the end of the world, but it’s not. It may be the end of long road trips. It is also the start of the realization that, similar to needing reading glasses, he is not immortal but actually a simple human being.

The prostate is a gland the size of a walnut at the base of the penis. It wraps around the urethra (the tube that urine comes from). A prostate is essential for normal male fertility, as it is responsible for making fluid that protects and nourishes sperm. Everything is shipshape until a man gets older, when two problems can arise. One is benign prostatic hypertrophy (BPH), which is a fancy way of saying enlargement of the prostate. This occurs in about half of all men in their sixties. For reasons still unclear, the prostate continues to grow as a man gets older. It is usually symptomatic – men have urinary urgency, dribbling, weak stream and may have to get up at night to urinate. The other problem is prostate cancer. Most commonly, cancer has no symptoms.

BPH is not preventable, but prostate cancer may be. Following a heart-healthy, low-fat, low carbohydrate diet is key to the prevention strategy, as are exercise, weight management and stress reduction. Concentrate on fruits and vegetables, which are high in antioxidants that protect the cells of your body from becoming cancerous. Soy and green tea may also protect the prostate. Sugar intake should also be limited, as it often ends up stored in your body as fat, and obesity is linked to prostate cancer.

That said it may surprise you to know that prostate cancer doesn’t always kill. Cancer is no one’s friend, but prostate cancer is not as deadly as lung cancer, colon cancer or breast cancer. It is much more slow-growing than these other cancers, doubling in size every 2-3 years instead of every 4-6 months. As such, a man is eight to ten times more likely to die of heart disease than prostate cancer. Even more interesting, some believe that prostate cancer is really a disease of age in men, as the likelihood of having small amounts of cancer in the prostate goes up with age. That means that about 80% of 90 year old men will have prostate cancer, and may never know it. They will likely die of unrelated causes. It also means that there are many prostate cancers occurring in men that are “clinically insignificant,” a rare term in cancer medicine. So, many prostate “cancers” actually don’t act as such.

Although diseases of the prostate are rarely lethal, they can affect your quality of life…and your road trips. Men over forty should start to have the prostate checked regularly, although most men would rather spend quality time with the dentist’s drill than go in for that exam. Blood tests for a substance called PSA, can also help detect cancer. The symptoms of prostatic enlargement can treated with pills; if these don’t work, various, safe but indescribable procedures can remove the symptom-causing prostatic tissue. Some of the FDA approved pills to treat BPH also prevent prostate cancer. Now that’s a pill that men might want to swallow. So, for all kinds of reasons, don’t ignore the prostate. Try to attend to it before it disrupts the flow of your daily life.

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