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A Harvard expert shares his thoughts on testosterone …

Posted: January 29, 2019 at 6:42 am

An interview with Abraham Morgentaler, M.D.

It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.

Over time, the testicular machinery that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism (hypo meaning low functioning and gonadism referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5% of those affected receiving treatment.

Studies have shown that testosterone-replacement therapy may offer a wide range of benefits for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.

Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Mens Health Boston, specializes in treating prostate diseases and male sexual and reproductive difficulties. He has developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and why he thinks experts should reconsider the possible link between testosterone-replacement therapy and prostate cancer.

What signs and symptoms of low testosterone prompt the average man to see a doctor?

As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.

The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these soft symptoms as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.

Arent those the same symptoms that men have when theyre treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity usually does not go along with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, its more of a challenge to get a good erection.

How do you determine whether a man is a candidate for testosterone-replacement therapy?

There are two ways that we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think thats a reasonable guide. But no one quite agrees on a number. Its not like diabetes, where if your fasting glucose is above a certain level, theyll say, Okay, youve got it. With testosterone, that break point is not quite as clear.

Is total testosterone the right thing to be measuring? Or should we be measuring something else?

Well, this is another area of confusion and great debate, but I dont think its as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. But about half of the testosterone thats circulating in the bloodstream is not available to the cells. Its tightly bound to a carrier molecule called sex hormonebinding globulin, which we abbreviate as SHBG.

The biologically available part of total testosterone is called free testosterone, and its readily available to the cells. Almost every lab has a blood test to measure free testosterone. Even though its only a small fraction of the total, the free testosterone level is a pretty good indicator of low testosterone. Its not perfect, but the correlation is greater than with total testosterone.

This professional organization recommends testosterone therapy for men who have both

Therapy is not recommended for men who have

Do time of day, diet, or other factors affect testosterone levels?

For years, the recommendation has been to get a testosterone value early in the morning because levels start to drop after 10 or 11 a.m. But the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest amount, and probably not enough to influence diagnosis. Most guidelines still say its important to do the test in the morning, but for men 40 and above, it probably doesnt matter much, as long as they get their blood drawn before 5 or 6 p.m.

There are some very interesting findings about diet. For example, it appears that individuals who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasnt been studied thoroughly enough to make any clear recommendations.

In this article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone testosterone that is manufactured outside the body. Depending on the formulation, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.

Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the production of natural testosterone, termed endogenous testosterone, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, all of the men had heightened levels of testosterone; none reported any side effects during the year they were followed.

Because clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves and possibly enhances sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who want to father children.

What forms of testosterone-replacement therapy are available?*

The oldest form is an injection, which we still use because its inexpensive and because we reliably get good testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every few weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and then return to baseline. [See Exogenous vs. endogenous testosterone, above.]

Topical therapies help maintain a more uniform level of blood testosterone. The first form of topical therapy was a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area on their skin. That limits its use.

The most commonly used testosterone preparation in the United States and the one I start almost everyone off with is a topical gel. There are two brands: AndroGel and Testim. The gel comes in miniature tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who dont absorb enough for it to have a positive effect. [For specifics on various formulations, see table below.]

Are there any drawbacks to using gels? How long does it take for them to work?

Men who start using the gels have to come back in to have their testosterone levels measured again to make sure theyre absorbing the right amount. Our target is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, though symptoms may not change for a month or two.

What about pills?

There are pills in the United States for testosterone supplementation, but their use is strongly discouraged because they cause significant liver toxicity. A safe oral formulation called testosterone undecanoate is available in Canada and in Europe, but not in the United States. Whats quite exciting is that an injectable version of testosterone undecanoate (Nebido) was submitted to the FDA for approval in August 2007. (Its already approved in many other countries.) It lasts for 12 weeks, so a patient could come in and get a shot about four times a year. [Editors note: In December 2009, the brand name of the drug in the United States was changed to Aveed. As of January 2011, it was still awaiting FDA approval.]

Cherrier MM, Asthana MD, Plymate S, et al. Testosterone Supplementation Improves Spatial and Verbal Memory in Healthy Older Men. Neurology 2001;57:8088. PMID: 11445632.

Isidori AM, Giannetta E, Greco EA, et al. Effects of Testosterone on Body Composition, Bone Metabolism and Serum Lipid Profile in Middle-aged Men: A Meta-analysis. Clinical Endocrinology 2005;63:28093. PMID:16117815.

Liu PY, Swerdloff RS, Veldhuis JD. Clinical Review 171: The Rationale, Efficacy and Safety of Androgen Therapy in Older Men: Future Research and Current Practice Recommendations. Journal of Clinical Endocrinology and Metabolism 2004; 89:478996. PMID: 15472164.

Moffat SD, Zonderman AB, Metter EJ, et al. Longitudinal Assessment of Serum Free Testosterone Concentration Predicts Memory Performance and Cognitive Status in Elderly Men. Journal of Clinical Endocrinology and Metabolism 2002;87:50017. PMID: 12414864.

Wang C, Cunningham G, Dobs A, et al. Long-term Testosterone Gel (AndroGel) Treatment Maintains Beneficial Effects on Sexual Function and Mood, Lean and Fat Mass, and Bone Mineral Density in Hypogonadal Men. Journal of Clinical Endocrinology and Metabolism 2004;89:208598. PMID: 15126525.

Other than improvement in sexual symptoms, what are some of the potential benefits of testosterone-replacement therapy?

Some studies have looked at testosterone therapy and cognition. Although the findings werent definitive, there was some evidence of cognitive improvement. Other studies have shown that it improves mood. Testosterone therapy has also been shown to be effective in the treatment of osteoporosis and in increasing muscle bulk and strength. [See Testosterones impact on brain, bone, and muscle, above.]

What risks do you consider when prescribing testosterone-replacement therapy?

When patients ask about risks, I remind them that they already have testosterone in their system and that the goal of testosterone treatment is to restore its concentration back to what it was 10 or 15 years previously. And the molecule itself that we give is identical to the one that their bodies make naturally, so in theory, everything should be hunky-dory. But in practice, there are always some curveballs.

For example, testosterone can increase the hematocrit, the percentage of red blood cells in the bloodstream. If the hematocrit goes up too high, we worry about the blood becoming too viscous or thick, possibly predisposing someone to stroke or clotting events. Although, frankly, in a review that I wrote in the New England Journal of Medicine* where we reviewed as much of this as we could, we found no cases of stroke or severe clotting related to testosterone therapy. Nevertheless, the risk exists, so we want to be careful about giving testosterone to men who already have a high hematocrit, such as those with chronic obstructive pulmonary disease, or those who have a red-blood-cell disorder.

Although its rare to see swelling caused by fluid retention, physicians need to be careful when prescribing testosterone to men with compromised kidney or liver function, or some degree of congestive heart failure. It can also increase the oiliness of the skin, so that some men get acne or pimples, but thats quite uncommon, as are sleep apnea and gynecomastia (breast enlargement).

What about the risk of developing prostate cancer?

I think that the biggest hurdle for most physicians prescribing testosterone is the fear that theyre going to promote prostate cancer. [See Incongruous findings, below.] Thats because more than six decades ago, it was shown that if you lowered testosterone in men whose prostate cancer had metastasized, their condition improved. (It became a standard therapy that we still use today for men with advanced prostate cancer. We call it androgen deprivation or androgen-suppressive therapy.) The thinking became that if lowering testosterone makes prostate cancer disappear, at least for a while, then raising it must make prostate cancer grow. But even though its been a widely held belief for six decades, no one has found any additional evidence to support the theory.

Havent there been any studies that follow men who go on testosterone-replacement therapy to see what their rate of cancer is compared with that in men who are not on it?

As with a number of treatments or medicines that have been around for a long, long time, it hasnt been scrutinized like a new drug would be. And although theyve been discussed, there arent any large-scale, randomized controlled clinical trials of testosterone-replacement therapy under way. [See A male equivalent to the Womens Health Initiative? below.]

There have been a number of smaller studies on men receiving testosterone-replacement therapy, and if you look at the results cumulatively, the rate of prostate cancer in these men was about 1% per year. If you look at men who show up for prostate cancer screening, same sort of age population, the rate tends to be about the same. You have to be cautious in comparing studies and combining the results, but theres no signal in these results that testosterone-replacement therapy creates an unexpectedly high rate of prostate cancer.

We also have epidemiologic studies, like the Physicians Health Study, the Baltimore Longitudinal Study of Aging, and the Massachusetts Male Aging Study, that include tens of thousands of men who are followed for 5, 10, 15, or even 20 years. At the end of the study period, the researchers see who developed prostate cancer and who didnt. They can then look at blood samples taken at the start of the study to see if, for example, the group that got prostate cancer had a higher level of testosterone over all. About 500,000 men have been entered in some 20 trials of this type around the world. Not one of those studies has shown a definitive correlation between prostate cancer and total testosterone. Three or four have shown weak associations, but none of those have been confirmed in subsequent studies.

Another point Id like to make for people worried about a link between high testosterone and prostate cancer is that it just doesnt make sense. Prostate cancer becomes more prevalent in men as they age, and thats also when their testosterone levels decline. We almost never see it in men in their peak testosterone years, in their 20s for instance. We know from autopsy studies that 8% of men in their 20s already have tiny prostate cancers, so if testosterone really made prostate cancer grow so rapidly we used to talk about it like it was pouring gasoline on a fire we should see some appreciable rate of prostate cancer in men in their 20s. We dont. So, Im no longer worried that giving testosterone to men will make their hidden cancer grow, because Im convinced that it doesnt happen.

Can testosterone worsen BPH?

The evidence shows that testosterone treatment does not change the strength or rate of urine flow, does not change the ability to empty the bladder, and does not change other symptoms such as frequency or urgency of urination, as assessed by the American Urological Association Symptom Score or the International Prostate Symptom Score. Ive had a couple of patients over the years who had some worsening of urinary symptoms with testosterone, but thats rare, even with long-term use.

Studies have come to conflicting conclusions about whether high levels of testosterone increase the risk of developing prostate cancer. A sampling of studies that have helped drive the controversy follows.

Increases in cancer risk

Parsons JK, Carter HB, Platz EA, et al. Serum Testosterone and the Risk of Prostate Cancer: Potential Implications for Testosterone Therapy. Cancer Epidemiology, Biomarkers, and Prevention 2005;14:225760. PMID: 16172240.

Shaneyfelt T, Husein R, Bubley G, et al. Hormonal Predictors of Prostate Cancer: A Meta-Analysis. Journal of Clinical Oncology 2000;18:84753. PMID: 10673527.

No effect or decreases in cancer risk

Eaton NE, Reeves GK, Appleby PB, et al. Endogenous Sex Hormones and Prostate Cancer: A Quantitative Review of Prospective Studies. British Journal of Cancer 1999;80:93034. PMID: 10362098.

Mohr BA, Feldman HA, Kalish LA, et al. Are Serum Hormones Associated with the Risk of Prostate Cancer? Prospective Results from the Massachusetts Male Aging Study. Urology 2001;57:93035. PMID: 11337297.

Morgentaler A. Testosterone and Prostate Cancer: An Historical Perspective on a Modern Myth. European Urology 2006;50:93539. PMID: 16875775.

Mixed findings

Slater S, Oliver RT. Testosterone: Its Role in the Development of Prostate Cancer and Potential Risks from Use as Hormone Replacement Therapy. Drugs and Aging 2000;17:43139. PMID: 11200304.

Whats your strategy for the concomitant administration of erectile dysfunction drugs?

My preference is to start men on testosterone, for a couple of reasons. First, if a man has successful return of his own erections, its like a home run for him. He doesnt have to take a pill in anticipation of having sex. He can have sex whenever he wants. Second, the benefits of testosterone-replacement therapy often go way beyond erectile dysfunction. That may be what brought the patient into the office originally, but then he comes back saying how much better he feels in general, how much more energetic and motivated he is, how his drives on the golf course seem to be going farther, and how his mood is better.

But if somebody fails testosterone therapy, meaning that their erections arent any better, Ive said, Well, lets stop the testosterone and try one of the PDE5, or phosphodiesterase type 5, inhibitors sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). A lot of patients then say, Well, actually, Id like to stay on the testosterone. True, its not helping my erections, but Im more turned on, and Im getting these other benefits. So we often continue the testosterone and add a PDE5 inhibitor.

Theres a significant failure rate of the PDE5 inhibitors for erectile dysfunction, something on the order of 25% to 50%, depending on the underlying condition. It turns out that a third of those men will have adequate erections with testosterone-replacement therapy alone and another third will have adequate erections with the pills and testosterone combined. Theres still a third who dont respond, but normalizing their testosterone level has definitely rescued many men who had failed on PDE5 inhibitors.

In 2002, the federally sponsored Womens Health Initiative (WHI) stopped its hormone replacement therapy (HRT) trial (estrogen plus progestin), which included more than 16,000 women, three years early because those taking the pills had an increased risk of developing breast cancer and blood clots, and an increased risk of suffering a stroke or heart attack than those taking a placebo. The findings ran counter to the long-held belief that HRT could preserve health and trim heart-disease risk in women.

Unlike previous studies of HRT, which had been observational in nature, the WHI was a double-blind, randomized controlled trial. The gold standard of scientific inquiry, these trials can conclusively test theories and assess cause and effect.

To date, no large, double-blind, randomized controlled studies of a link between testosterone treatment and prostate cancer have been completed. In its 2004 report, the Institute of Medicine (IOM) committee studying the need for clinical trials of testosterone-replacement therapy noted that only 31 placebo-controlled studies had been done in older men, with the largest one enrolling just 108 participants. Most of these studies lasted only six months.

The IOM report estimated that a study of whether there is an increased risk of prostate cancer in men on testosterone therapy might require following 5,000 men for three to five years. Before launching such an endeavor, the report recommended more firmly establishing the effectiveness of testosterone-replacement therapy, saying that studies of long-term risks and benefits should be conducted only after short-term efficacy has been proven. That means the male equivalent of the WHI remains far off.

Whats your thinking on performing a prostate biopsy before prescribing testosterone therapy?

I started doing prostate biopsies before putting men on testosterone therapy because the fear had always been that a hidden cancer might grow due to increased testosterone. It was also believed that low testosterone was protective. Well, we found prostate cancer in one of the first men with low testosterone we biopsied, even though his PSA level and digital rectal exam (DRE) were normal. As we did more of these, we found more and more cases, about one out of seven, despite normal DRE and normal PSA. When we had data for 77 men and the cancer rate was about the same, 14%, the Journal of the American Medical Association published our findings. At the time, that rate of prostate cancer in men with normal PSA was several times higher than anything published previously, and it approximated the risk of men who had an elevated PSA or an abnormal DRE. That was in 1996.

In a subsequent study of 345 men with normal PSA and low testosterone, we found the cancer rate was similar: 15%. And we had a large enough group to look at the impact of testosterone on cancer risk. For men whose total testosterone or free testosterone value was in the lowest third, the odds of having a positive biopsy were double the odds in the rest of the men. Thats the first evidence that low testosterone may be an independent predictor for the development of prostate cancer.

That would argue for doing a routine prostate biopsy on anyone considering testosterone-replacement therapy.

Its not universally accepted, but thats what I do. Several recent studies have shown that low testosterone is associated with higher Gleason scores, with advanced-stage prostate cancer, and, even worse, with shorter survival times. [See Low testosterone, PSA, and prostate cancer, below.]

What recommendations do you have for monitoring once testosterone therapy begins?

The general recommendation is that men 50 and older who are candidates for testosterone therapy should have a DRE and a PSA test. If either is abnormal, the man should be evaluated further for prostate cancer, which is what we do with everybody whether they have low testosterone or not. That means a biopsy. But if all of those results are normal, then we can initiate testosterone therapy. The monitoring that needs to happen for men who begin testosterone therapy is really very simple: DRE, PSA, and a blood test for hematocrit or hemoglobin, once or twice in the first year and then yearly after that, which is pretty much what we recommend for most men over age 50 anyway.

Morgentaler A, Rhoden EL. Prevalence of Prostate Cancer Among Hypogonadal Men with Prostate-Specific Antigen Levels of 4.0 ng/dL or less. Urology 2006;68:126367. PMID: 17169647.

Morgentaler A, Bruning CO 3rd, DeWolf WC. Occult Prostate Cancer in Men with Low Serum Testosterone Levels. Journal of the American Medical Association 1996;276:19046. PMID: 8968017.

Massengill JC, Sun L, Moul JW, et al. Pretreatment Total Testosterone Level Predicts Pathological Stage in Patient with Localized Prostate Cancer Treated with Radical Prostatectomy. Journal of Urology 2003;169:16705. PMID: 12686805.

Isom-Batz G, Bianco FJ Jr, Kattan MW, et al. Testosterone as a Predictor of Pathological Stage in Clinically Localized Prostate Cancer. Journal of Urology 2005;173:193537. PMID: 15879785.

What changes do you see taking place on the testosterone front over the next five years?

I think that the importance of testosterone for cardiovascular health is going to be increasingly recognized. In the past, because men die of heart attacks more often than women and men have more testosterone, the fear has been that testosterone causes heart problems. But every single study of whether testosterone is bad for the heart has been negative, and what people havent pointed out in most of those negative studies is that there may be a beneficial effect.

I think well also find out in five years that there very well may be general health benefits of having normal testosterone compared to low testosterone. There are growing data for all-cause mortality that men who have low testosterone die earlier than those who have normal testosterone. A study by the Veterans Administration reported about a year ago showed low testosterone levels were associated with a dramatically increased mortality rate. Its hard to know why that is, but I think well be focused on that in the coming years.

Any closing thoughts?

I think that low testosterone is under-recognized, its effects are greatly underappreciated, and its diagnosis isnt readily understood. This is an area that has tremendous research potential in the coming years.*

Originally published March 2009; last reviewed February 18, 2011.

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A Harvard expert shares his thoughts on testosterone ...

Weight Loss with VEEP – Visual Eating and Exercise Plan

Posted: January 27, 2019 at 1:43 am

Weight Loss with VEEP - Visual Eating and Exercise Plan

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This information presented in this program is for educational purposes only. This information does not replace the advice of a qualified medical professional or diagnose or treat any medical condition and should not be relied on as such. If you have any concerns or questions about your health you should always consult with a physician or other health-care professional. Do not avoid or delay obtaining medical or health related advice from your health-care professional because of something you may have read on this site or learn in this program. The use of any information provided on this site or in this program is solely at your own risk.

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Weight Loss with VEEP - Visual Eating and Exercise Plan

5 Surprisingly Easy Ways To Fast-Track Your Weight Loss

Posted: January 27, 2019 at 1:43 am

Wanna fast-track your weight loss? Forget peeking at the scale turn your attention to the fridge

Chances are you unpack your weekly grocery shopping with as much thought as you give to Sundays laundry. A triangle of Brie on the top shelf; milk in the left-hand corner with the garlic and dark chocolate. Be warned: research shows where you put your food can have a big impact on how you eat, so its time to become fridge aware. Heres how to stack and snack yourself slimmer.

READ MORE: These 3 Drinks Will Help You Lose Weight And Theyre Not Vinegar

Ever open your fridge and feel like its an out-take from TLCs Hoarding: Buried Alive? We know the feeling. What we bet you didnt know, though, is research from the Journal of Consumer Psychology found a cluttered fridge can crush your willpower. Weight-loss coach Nicky Anstey explains that in a busy fridge, the bright, attractive packaging of less healthy products distracts you from the more earthy colours of your fresh produce theres a reason McDonalds chose a red and yellow colour scheme.

Both these colours have been proven to boost your appetite, particularly red, which signals ripeness and sweetness, according to research published in the Journal of Sensory Studies. So ditch the strawberry cheesecake and replace it with red- or yellow-hued healthy snacks. Pass the peppers, please.

READ MORE: Heres How To Use Ginger To Cut Your Body Fat

Place your healthiest snacks and food with the most nutrients at eye level, says eating and behavioural therapist James Lamper. So if you get the munchies, theyll be the first thing you see when you open the fridge. According to a US study, youre 2.7 times more likely to eat healthy food if its in your line of sight. If you want to go the extra mile, store your naughty treats at the back of the fridge and the bottom of the pile. A study led by nutritional behaviour professor Dr Brian Wansink suggests the more inconvenient the location of your chocolate, the less likely you are to reach for it.

READ MORE: 3 Really Smart Ways To Stop Yourself From Eating Too Much

A study published in the Journal of Marketing found people eat larger quantities of junk food if its kept in clear packages. The same research also showed when your naughty treats are bite size, youre more likely to eat more. Our advice: buy the bowling ball of Edam rather than seductive mini cheeselings. And keep your chocolate and cheese in opaque Tupperware at the back of the fridge. Plus, if you can, make the containers blue. Studies show that blue is a common appetite suppressant.

READ MORE: The 12 Best Foods To Burn Fat And Build Lean Muscle

A healthy snack can curb hunger throughout the day and keep you fuller for longer. Try make your snacks fruit and veg and ensure theyre pre-cut that way youre more likely to munch them. After hitting the supermarket, immediately wash, cut and store. Also place that tub of pre-cut veggies next to a tub of hummus or low-kilojoule yoghurt-dill dip. Carrot sticks? Bleh. Carrot sticks and dip? Mmm, much more appealing!

READ MORE: 5 Rules That Actually Work If Youre Trying To Lose Weight

Kilojoule-conscious eating doesnt mean boring fare. Keeping an arsenal of diet-friendly flavourings inside the door of your fridge can make any meal moreish. Try mustard, low-sodium soy sauce, Tabasco and herbs like chives, thyme and rosemary. They can be loosely placed in cling film and popped in the warmest part of the fridge (one of the compartments in the door).

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5 Surprisingly Easy Ways To Fast-Track Your Weight Loss

Weight Loss: Consume These 3 Drinks Just Before Bedtime To …

Posted: January 27, 2019 at 1:43 am

Highlights

If you happen to be one of those who are struggling to shed some extra pounds, then this article is just for you. Losing weight is not an easy task - it calls for a balanced diet and proper workout regime. However, to up the pace of weight loss process, there are a few diet hacks that you can practice during bedtime. These hacks are simple yet can help you lose weight fast by increasing the body's metabolism and boosting your digestion process. According to Ayurveda Expert, Dr. Ashutosh Gautam, "In order to lose weight effectively, one should have a good digestive system."

An improved digestive system is the first step in the weight loss journey. By increasing digestive efficiency with a few dietary changes, one can effectively lose weight and boost body's metabolism. If you feel bloated most of the time, then consumption of these drinks will help you stay at ease.

Weight Loss: An improved digestive system is the first step in the weight loss journeyPhoto Credit: iStock

Cinnamon Tea

Cinnamon is loaded with various antioxidant and antibiotic properties

To make cinnamon tea, you'll need 1 cup of boiling water and 1 teaspoon of cinnamon powder. Mix them together and allow it to steep for around 20-30 minutes. Sip a cup of cinnamon tea at least half an hour before going to bed for effective results.

(Also Read -6 Amazing Benefits of Honey and Cinnamon)

Soaked Fenugreek Water

According to Dr. Ashutosh, "Fenugreek seeds facilitate weight loss to a great extent. Regular consumption of methi dana generates heat in the body and helps in managing and losing weight. It also acts as a great antacid and helps strengthen the digestive system. It should be consumed at least half an hour or one hour before bedtime." Boil the water in a container and add the crushed fenugreek seeds in it. You can crush these seeds using mortar and pestle. Cover and steep the seeds for at least three to five minutes. Strain in a cup using a regular tea strainer and reap out its benefits.

(Also Read - Fenugreek Seeds: Here's How Eating Soaked or Sprouted Methi Dana will Benefit Your Health)

Chamomile Tea

Chamomile not only stimulates weight loss, but also reduces bloating to a great extent. Loaded with calcium, potassium and flavonoids, chamomile's ability to detox the body helps in getting rid of toxins and excess water. A cup of hot chamomile tea before bedtime could help you get a restful sleep as well.

Now, that we have shared with you a list of bedtime hacks, make them a part of your daily schedule and lose weight effectively. These detox drinks can help flush out toxins from the body. With an improved digestion and good metabolism, you'll be able to lose weight fast.

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Weight Loss: Consume These 3 Drinks Just Before Bedtime To ...

Best 401+ How To Go On A Liquid Diet Safely Free Instant …

Posted: January 27, 2019 at 1:43 am

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The Best 421+ How To Go On A Liquid Diet Safely Free Download PDF Video. If you want to burn off pounds fast, you will to find the most effective diet plan that suits into your lifestyle.. The very first thing that you need to know is a balanced diet to lose fat and not muscle.. The first thing you need to do to eliminate belly fat is reducing your intake of carbs. You will not be exhausted, and as you count calories depending on low-carb you proceed. The diet may tend to be a high protein diet plan.. The best strategy to lose weight faster is to shed weight through the most suitable fat reduction plan.. You would remain just the identical weight and swap 10 lbs. of fat for 10 pounds of muscle. Keeping a wellness and fitness and nutrition routine that is rich up is your strategy.. Its simple to find the most effective diet plan to get started. With the modifications, you will find it much simpler to stick to the low-carb diet..

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13 Yoga Asanas for Weight Loss | Avocadu

Posted: January 27, 2019 at 1:42 am

Looking for the best yoga asanas for weight loss? Youve come to the right place. Perhaps the best part about yoga is that it will help you lose weight but also while building muscle and improving flexibility!

Yoga is touted as a way to burn fat without breaking a sweat! But is this really true? Were here to tell you

Hell yeah, it is!

Yoga has many benefits,including helping you lose weight!

Aside from thephysical side of it that helps you burn calories, the main reason yoga can help you lose weight actually comes from the mental side of it.

We all know that stress leads to a poor diet. Yoga helps to greatly reduce stress, which not only helps you make better decisions but also lowers cortisol levels.

Cortisol is the stress hormone that causesweight gain. Lowering your cortisol levels will help you naturally lose weight.

As far as the physical aspect of it Wed like to remind you that you will get out of it what you put into it.

Anyone can go through the motions in yoga withoutreally trying. Yoga is about challenging your mind and your body and taking it to new lengths. If you challenge yourself, you will burn more calories, and you will lose more weight.

Asana is roughly translated from Sanskrit as pose or posture. This simply means a yoga pose.

The literaltranslation actually means to be in a comfortable seated position. This comes from the branch of yoga called ashtanga yoga, and it refers to the physical exertion andalso the mental relaxation that happens in yoga. Practicing these asanas will bring you awareness both internally and externally.

The poses below also have their Sanskrit name beside them.

Many of the poses below have the instructions to repeat on the other side. This means that it is a two-sided pose, and it only works muscles in one side of the body at a time. Always repeat the pose on both sides of the body to build strength and flexibility equally in the body.

Traditionally, your hands should be touching the floor in front of you in this pose, but we like the extra shoulder stretch!

Spread your feet 3-4 feet apart, and bend forward at the HIPS, not the waist. This means that your back should be as straight as possible when you bend, and you should not simply hunch forward.

If youre bending properly, you will actually feel a strong stretch in the hamstrings. Practice in front of the mirror to try to get the correct form.

Hold for 5-6 breaths.If you feel comfortable enough, clasp the hands behind the back. Try to bring them up towards the ceiling to give the arms and shoulders an extra stretch.

This is one of the best poses for stretching the hips. Many people tend to have tight hips from sitting in front of a computer all day. It will also help increase your flexibilityfor the splits if that happens to be one of your goals.

Keep in mind that your hands can be wherever you want them to be in this asana, and their location often determines what muscles you are stretching.

If youraise the arms up and tilt them backward, you will bring this stretch into the back as well as the hips. You can also bring the arms down to your sides and behind you a bit to stretch the lower back. The third option is to rest them on the knee in front of you, although you wont get as deep of a stretch in the hips.

Make sure your front knee is as close to 90 degrees as possible.

Hold for 30 seconds, and repeat on the other side.

This is a great yoga asana for weight loss because it directly works the tummy! Youll feel your ab muscles working hard as you try to hold this pose.

Put your palms down on the ground for balance, and raise the legs first. When you feel stable enough, raise the arms so that they are parallel with the ground.

If you feel that this is too easy, try increasing the space between your knees and chest by leaning back a little and moving the knees a little farther away from you. You should feel your abs burning if youre doing it right!

Hold for 30 seconds.

If you feel comfortable in this pose, try straightening the legs for an extra challenge. This is full boat pose, and it is much more difficult to balance in.

Its no wonder that some form of the plank made this list of yoga asanas for weight loss. The plank and all of its variations are great for the abs!

Begin in regular plank position with your palms face down on the yoga mat, shoulder-width apart,and your toes together on the mat.

Tilt your feet to the left so that the outer right side of your right foot is touching the mat and the left foot is on top of the right (as pictured above).

Shift your weight onto your right hand as you remove your left hand from the ground. Slowly lift your leftarm straight up ahead of you towards the ceiling.

Your hips and shoulders should be stacked in this pose, meaning that they should directly in line with each other and not leaning forward or backward.

Hold for 30 seconds, and repeat on the other side.

Dont be fooled by tree pose. Its harder to balance in this pose than it looks!

Bring your left foot in to rest on the inside of your left thigh. Keep your back straight. Your body may have a tendency to lean forward when trying to balance but bring your shoulders back up.

Keep your hands pressed together at your heart to help with balance, then try lifting them above your head with your hands pointed towards the ceiling.

Hold for 30 seconds, and repeat on the other side.

If you need to, keep the right hand on the floor next to the left foot for support while getting into this pose.

Try to keep your front knee bent at a 90-degree angle and your outstretched leg straight.

Bring your right elbow to rest on your left knee, and bring the hands together. Press the hands into each other to increase the stretch in the back and shoulders.

Tighten your core while in this pose for an extra workout in the abs!

Hold for 5-6 breaths or up to 30 seconds, and repeat on the other side.

This is the yoga version of a squat hold and also deserved a spot amongst the yoga asanas for weight loss. You will feel it in your quadriceps.

Keep the feet together and the arms straight above you as you lower into a squatting position.

Make sure that you can still see yourfeet in front of your knees. If you cant, your knees are bent too far forward.

Try to tuck your hips in slightly, and avoid arching the back too much.

Try to get your thighs as close to parallel to the floor as possible without compromising your form.

Hold for 30 seconds.

Warrior I is often performed as a vinyasa with Warrior II and Warrior III (below). This simply means that they are performed as a flow, in which you go from one pose to another fluidly.

The warrior routine is an important part of the yoga asanas for weight loss and should not be ignored.

Warrior I is similar to a high lunge, but the back foot is pointed out at an angle rather than tucked under.

Try to keep the front knee at a 90-degree angle, but for many beginners, your stance may look like the photo above (slightly higher than 90 degrees).

Try to hold it for 30 seconds, and transition into Warrior II (below). Note: You will want to repeat all 3 of these poses as a vinyasa on the other side of the body after you are finished with the first side.

From Warrior I (above), you will simply extend the arms out to both sides, like pictured above, as you move your chest and hips to face the same direction as your back foot.

Again, try to keep the front knee at as close to a 90-degree angle as possible.

The arms should be parallel to the floor.

Try to hold it for 30 seconds, and transition into Warrior II (below). Note: You will want to repeat all 3 of these poses as a vinyasa on the other side of the body after you are finished with the first side.

Warrior III is the most difficult of this vinyasa. It may look easy enough, but holding this pose with the right form for more than a few seconds can be quite difficult for beginners!

From Warrior II, twist your chest to face the forward direction again. Bring your arms straight out in front of you for balance.

Beginners to yoga will probably need to bring the back leg up closer to the front to stay balanced before lifting it. Bring your palms together at your chest as you begin to lift your leg up in the air because it helps tremendously with balance.

Once you get into position, slowly raise your arms out in front of you. Note that the back toes should actually be pointed for true form, but beginners can work on that from the photo above.

It will take time, strength, and flexibility to improve your form in this asana. Practice in front of a mirror, and practice it often.

Try to hold for 30 seconds, and then repeat the entire vinyasa on the other side of the body.

This is considered an inversion because your body is upside down! Inversions such as headstand, forearm stand, and handstand can make yoga practice very fun!

Begin with your back on the ground, your knees slightly bent, and your feet in the air. Press your hands flat on the ground, and use them to roll yourself backward on your upper back. As you do this, bring the hands to your lower back, just above your hips, to keep yourself upright.

Slowly extend your legs toward the ceiling.

Beginner Modification: If youre having difficulty staying up, place your hands on your hips to help support your weight better.

Hold for 5-6 breaths, and work towards 30 seconds.

This is one of the more beginner yoga asanas for weight loss, but it works and feels great to stretch in!

From a standing position, take hold of your left ankle with your left hand. Shift your weight forward, and place your right hand on your right knee for support.

As you lean forward, arch your back, and press outward with your left foot. Tilt your tailbone back to support the arch in the back.

Slowly raise your right arm forward when you feel that you are comfortable in the position. Make sure that theleft leg is completely straight.

Hold for 30 seconds. Repeat on the other side.

While this is one of the more advanced yoga posesfor weight loss, practicing it will help you burn calories and build arm strength!

Begin in a low squat with your hands on the mat in front of you and your fingers spread wide. Your knees should be wider than your arms.

Come up on your tiptoes, and place the knees on the edges of your upper arms. Your knees shouldnt be directly on the upper arms, but closer to the edges or outside of your upper arms.

Slowly shift your weight forward until your toes are just barely touching the ground. First, try to lift one foot up in the air, then the other. Keep your back rounded and your core engaged.

The goal is to eventually be able to hold the pose and straighten the arms completely.

Practice this several times per day, and you willbuild the strength and find the balance to hold it!

Those were the 13 yoga asanas for weight loss! We have one more asana that we included not because it can help you lose weight, but because it is a rest pose.

Yoga can put a lot of strain on the muscles and the body when youre stretching or working muscles that are not usedoften. Make sure to come into childs pose any time that your body feels like it needs a rest, especially in any sort of backbends such as lord of the dance pose or wheel pose.

Bend the knees, and sit lightly between the heels. Your knees should be out wide on either side of you. Rest your forehead on the ground in front of you.

The arms can be behind you or stretched out in front of you. This is a total relaxation pose and you shouldnt be working anything in it. Just focus on resting what feels sore. Hold for 5-6 breaths or as long as you need it before moving onto the next pose.

Childs pose is often done at the end of practice as well to cool down or reflect on your practice.

Remember that the hardest part of a yoga practice is getting yourself on the mat every day! Your health and well-being should be the highestpriority.

If you liked these poses for weight loss and are DONE with feeling self-conscious about your body, you need to check out ourYoga Fat Loss Bible for Beginners!

It comes witheverything you need to get started, includinga complete 6-week workout plan, a flexibility guide, and a beginners guide to meditation!

Its agreat solution around for those looking to lose weight, get more flexible, and relieve aches and pains with a calm yoga practice.

It will show you exactly how to melt away stubborn body fat with a regular yoga practice and has the top 50 fat-burning yoga poses every beginner should learn.

You can check it out byclicking here.

Always remember that themost difficult part of doing yoga getting yourself on the mat!

If you enjoyed this article on the best yoga asanas for weight loss or have any questions, please feel free to leave a comment below!

Lauren at Avocadu

Hey there! I'm Lauren McManus, one half of the Avocadu team! Together, my boyfriend Alex and I run this website! We believe in quality over quantity and that diet determines 85% or more of your health and well-being. In short, we believe in being healthy from the inside out.

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13 Yoga Asanas for Weight Loss | Avocadu

The Best Over-the-Counter Weight Loss Products That Work …

Posted: January 27, 2019 at 1:42 am

What to Look For

There are literally hundreds of over-the-counter weight loss products on the market. Most claim that they are safe and work quickly. Look for products that have be proven to be safe with no side effects, such as those containing green tea, guar gum, conjugated linoleic acid (CLA), chromium picolinate or 5-HTP. Green tea extract and chromium work by increasing calorie and fat metabolism and suppressing the appetite. 5-HTP works by increasing serotonin levels to the brain and can reduce sugar and other food cravings. As an appetite suppressant, it works fairly quickly.

There are many other ingredients in over-the-counter weight loss products. It is important to remember that over-the-counter products are not subjected to the same controls as prescription drugs. While some of these may work for quick weight loss in some people, they may not be safe to take, especially for long periods of time. Products containing bitter orange and country mallow may sound safe as they are natural substances, however, both can produce unpleasant side effects. Bitter orange may produce similar side effects to ephedra, which has now been banned by the FDA.

Most supermarkets and drug stores have a good range of weight loss aids. Walgreens has good value for money products including Natrol Green Tea 500 mg capsules, Schiff Green Tea Diet Tablets and Finest Natural Green Tea Capsules. Walgreens also stocks 5-HTP and chromium picolinate. Walmart stocks a good range of affordable dietary supplements including 5-HTP, chromium picolinate and green tea extract. Other mainstream retailers include the Vitamin Shoppe, Atkins and GNC. GNC has a wide range of weight loss products including its own brand.

Over-the-counter weight loss products can cost anywhere from $4.99 to $120.00, or more, depending on the brand and quantity involved. You dont necessarily need to spend more to get a better product. Many of the cheaper brands are just as effective. Some of the more expensive brands offer a money-back guarantee, but you will have to return the product directly to the manufacturer, rather than the store where you bought it.

You may also want to try some of the cereal bars and protein shakes that are part of some weight loss plans. Look for low-sugar varieties along with whey and rice protein shakes, which you can substitute for one of your main meals.

Remember there is no real substitute for a healthy diet and exercise. Eat plenty of fresh fruit and vegetables, whole grains, lean meat and fish, and try to exercise at least three times a week.

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Police Whitehall 1

Posted: January 24, 2019 at 6:44 pm

hoffman posted a photo:

Police Whitehall 1

Police line up outside Italian Embassy during a protest over the beating & jailing of anti globalisation protesters in Genoa during anti WTO & G8 demonstrations.
© Janine Wiedel. Distribution David Hoffman Photo Library phone +44(0)20 8981 5041, fax +44(0)20 8980 2041, email lib@hoffmanphotos.com
NUJ & BAPLA recommended terms & conditions apply. Moral rights asserted under Copyright Designs & Patents Act 1988.
Full terms and conditions for digital and traditional use available on request. Credit is required. No part of this photo to be stored, reproduced, manipulated or transmitted by any means without permission..© David Hoffman.david@hoffmanphotos.com

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Police Whitehall 1

Eating his Phone

Posted: January 24, 2019 at 6:44 pm

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Eating his Phone

Probably the best use of a phone I have ever seen

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Eating his Phone

The Lowdown on Testosterone Replacement Therapy | Berkeley …

Posted: January 22, 2019 at 4:46 pm

Promoters of prescription testosterone products promise that the hormone is nothing less than a fountain of youth for men of a certain age. And sales of these testosterone pills, gels, and patches have soared, nearly quadrupling in the United States between 2000 and 2011.

Many claims from drug companies and anti-aging clinics are directed at men who hope to regain their youthful vigor and improve their strength, sexual prowess, athletic performance, and appearance. Natural levels of the sex hormone normally decline with age. As they ebb, sex drive often slips into low gear, youthful energy fades, bones get thin and brittle, and physical ability sags, among other changes.

Some doctors began to surmise that testosterone replacement therapy could reverse certain age-related changes men experience, or at least hold them off for a while. But many men prescribed testosterone replacement therapy dont have an abnormally low blood level of testosteroneor havent even had the hormone measured.

Until recently, there has been little scientific evidence to support testosterone replacement, except for men whose bodies dont produce enough of the hormone, a medical condition called hypogonadism, or androgen deficiency. It differs from the natural process of decreasing testosterone that comes with normal aging, sometimes referred to as late-onset hypogonadism.

To test whether testosterone replacement offered older men any benefits, the National Institutes of Health sponsored a series of seven rigorously controlled, randomized trials, known as the Testosterone Trials, or TTrials, the largest of their kind.

Findings from four clinical trials were published in February 2017 by JAMA and JAMA Internal Medicine. Findings from the first three trials appeared in February 2016 in The New England Journal of Medicine.

The TTrials recruited 790 men ages 65 and older who had low testosterone levels and exhibited symptoms that could be related to low testosterone. Blood testosterone levels of 275 ng/dL (nanograms per deciliter) or below were considered low. Their low levels were attributed to aging and not to another recognized cause, such as hypogonadism.

Some men were randomly assigned to receive hormone replacement in the form of a 1 percent prescription gel applied to the skin daily. Others received a placebo, or inactive gel. Scientists tested whether testosterone replacement therapy offered any benefit over the course of one year. Heres what they found:

Sexual function. Testosterone replacement therapy modestly boosted sex drive and improved erections in men with low testosterone enrolled in the sexual function arm of the TTrials.

But improvements tended to decline over a year, leading experts to suggest that testosterone replacement therapy isnt as effective as drugs such as tadalafil (Cialis) and sildenafil (Viagra) for treating erectile dysfunctionalthough they wont help sex drive.

Physical function. Researchers studied whether testosterone replacement therapy improved mens walking speed over six minutes. Disappointingly, there was no difference between the testosterone group and the placebo group on either measure.

Vitality. In the trial that gauged how men rated their energy and vitality, testosterone replacement therapy fell flat. Scores for both the testosterone and placebo groups remained the same.

Bone density. Among the more encouraging findings is evidence that testosterone replacement therapy can help protect against bone loss. After a year on testosterone, volunteers who had normal bone density (none had osteoporosis) had a significant increase in bone mineral density and bone strength compared with men on a placebo.

Because the trial lasted only one year, researchers cant say with certainty that the increased bone density will ultimately lower fracture risk or if the same effect would be seen in men with osteoporosis. For now, men with low bone density and at high risk of fracture should look to proven osteoporosis medication, which has been studied for long-term use and is known to help prevent fractures.

Anemia. For years, doctors have been puzzled by a form of anemia (an abnormally low number of red blood cells) that appears in some men as they age. To test whether low testosterone levels might be the culprit, researchers studied the effect of testosterone replacement therapy on a group of 126 men with known and unknown causes of anemia.

After 12 months, testosterone treatment significantly increased their hemoglobin levels by stimulating the production of red blood cells: 58 percent of the men with unexplained anemia were no longer anemic, compared with only 22 percent of the men in the placebo group. Testosterone replacement therapy also helped men who had anemia from known causes, such as iron deficiency.

Brain health. Hopes ran high that testosterone replacement therapy might help counter some age-related changes affecting memory and cognition. No such luck. The Cognition Trial included 493 men with low testosterone and age-associated memory impairment. Testosterone replacement therapy offered no benefits for memory or other aspects of brain function.

Heart health. Some past studies have raised red flags that testosterone might increase the risk for heart attacks, strokes, and blood clots. The new findings add to those concerns.

Using scans to measure plaque in the arteries of 170 men with heart disease risk factors, researchers found that men on testosterone replacement therapy had more plaque buildup and greater narrowing of their arteries than men in the placebo group. The findings are worrisome because plaque buildup can raise the risk of a heart attack or a stroke.

'Low T': Fanning Fears and Making a Fortune

Is low-T making you feel like a shadow of your former self? Chances are youve seen that pitch, featured in slick TV or magazine ads that warn about the risks of low testosterone. Here's what you should know.

The TTrials have gone a long way in separating the hype from the real benefits testosterone replacement therapy may offer. But one important question remains unanswered: Is long-term testosterone replacement therapy use safe?

Because the TTrials were only one year long, they dont shed light much on the therapys risks. Some long-term studies have associated testosterone replacement therapy with prostate cancer, whereas others report no evidence that testosterone replacement therapy in men with low testosterone levels increases prostate cancer risk.

And concern remains about the effects of testosterone replacement therapy on cardiovascular health over time. In 2015, the U.S. Food and Drug Administration began requiring testosterone products to carry a warning about their associated risk for heart attack and stroke.

Other risks associated with testosterone replacement therapy include erythrocytosis (an abnormal increase of red blood cells) and benign prostatic hyperplasia (an enlarged prostate), or BPH.

Testosterone replacement therapy side effects include acne, breast enlargement, unwanted hair growth, and infertility. Men who have prostate or breast cancer, sleep apnea, BPH, or heart failure shouldnt use testosterone replacement therapy because it can worsen those conditions.

Most experts agree that doctors should consider testosterone replacement therapy only for men with proven low levels of testosterone who have symptoms that might improve with treatment, such as anemia, bone loss, or loss of sexual desire or function.

The only sure way to know whether your testosterone is low is to be diagnosed by a doctor, who will perform a physical exam, take your medical history, test your blood on at least two separate days, and rule out other conditions.

If youre considering testosterone replacement therapy, you might do well to start with a few healthy lifestyle changes that can offer even more benefits than hormone replacement.

Being overweight or obese is closely associated with low testosterone. Losing weight can raise hormone levels. Regular exerciseeven a brisk 30-minute walk a few times a weekcan improve vitality, strengthen muscles and bones, lower heart disease risk, and possibly even improve your sex life. Thats far more than testosterone replacement therapy can promise.

This article originally appeared in the July 2017 issue of Health After 50.

Also see Sex Boosters in a Bottle?

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