Dear Doctor: Are there any benefits to testosterone therapy for older men who have osteoporosis of the spine and hip? I understand that it comes with an increased chance of prostate cancer.

Dear Reader: These are smart questions to ask. Too many people think that men don't develop osteoporosis, but in fact, low testosterone is a prime risk factor for osteoporosis in men -- and not just in older men. Low bone density has clearly been shown in younger men whose testes produce very low levels of testosterone. For them, testosterone therapy has been shown to increase bone density after one year. For older men, the answers are more complex.

A 1996 study assessed the impact of testosterone therapy in 36 men with a median age of 58 who had testosterone deficiency verified by three different tests at different times. The men were given testosterone injections regularly for up to 18 months. At the end of the study, the testosterone had increased bone density in the spine by 5 percent while also increasing lean muscle mass and decreasing body fat.

A 2017 study looked at the impact in 211 men over the age of 65 (average age of 72) who had two morning testosterone readings below normal (lower than 275 nanograms per deciliter). The men were given the testosterone treatment AndroGel, of which they applied 5 grams daily to the skin for one year; a control group received a placebo gel. Both groups were given additional calcium and vitamin D. The testosterone group showed a 7.5 percent increase in bone density of the spine, while the placebo group showed an increase of only 0.8 percent. Hip bone density increased by 3.3 percent in the testosterone group, and by 2.1 percent in the placebo group.

A 2004 study also looked at men with low testosterone (below 350 ng/dL), with 24 men receiving an injection of 200 milligrams of testosterone every two weeks for three years, and 24 receiving a placebo injection every two weeks. At the end of the study, the testosterone group showed an improvement in spinal bone density by more than 9 percent; the placebo group showed no change. Again, there was only a slight improvement in hip bone density in the testosterone group.

Testosterone therapy clearly benefits men with low testosterone levels, so the natural question is: What about for men with normal levels? Unfortunately, there is no good data to support testosterone use in men with a normal level -- especially considering that testosterone increases both the size of the prostate gland and blood PSA levels. That is, there is a theoretical increased risk of prostate cancer with the use of testosterone. In men with low levels, using testosterone to bring those levels to normal may pose only a slight risk, but still, they should be monitored with PSA tests and prostate exams when on such therapy.

What appears to be more concerning is a slight increase in strokes and heart attacks in men using testosterone therapy. This risk appears to be correlated more strongly with injectable testosterone. And again, for men with lower levels, testosterone therapy may not show this risk.

In short, if your testosterone level is low and if you have a low risk for prostate cancer, you should consider testosterone therapy. Not only will it help build muscle mass, decrease fat, enhance libido and increase energy, it will also help increase your bone density.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Hello, dear readers! We're back with our monthly column to continue our conversation regarding your questions, concerns and thoughts about previous topics.

-- We'd like to begin with those of you who have written to us about specific medical issues that you or your loved ones are facing. As we've mentioned before, we can't give medical advice or suggest a diagnosis in this column. However, from the content of these letters, it's clear that you have been in contact with medical professionals.

If the medical information you have received is unclear, we urge you to follow up with your providers. Make a list of your questions. (And, as a reader has suggested, it's a great idea to make two lists and give one to the doctor.) Rank the questions in descending order of importance and then go over each issue until you receive an answer that you understand.

If you're still not getting the information you need in the form that you need it, we urge you to seek a second opinion. It can be from an entirely new doctor, or it can be from a different person in your own physician's office. It's quite possible that a nurse, nurse practitioner or physician's assistant in your health care provider's office or medical group may have a different approach to the issue that works better for you.

The final piece is to be sure to write everything down. It not only gives you a record of what was said that you can refer to in the future, but the simple act of writing something down also helps you to realize whether or not you are actually clear about what is being said.

-- We've had a number of readers ask about our answer to a woman who was experiencing urine leakage due to stress incontinence. When we stated that there are no approved medications for this problem, we meant stress incontinence only. As many of you pointed out in your emails and letters, urge incontinence, also known as overactive bladder, can be treated with an array of FDA-approved medications.

-- As scientists, we admire precision. In that spirit, we'd like to acknowledge a lapse that someone pointed out in our column about Candida auris, the so-called superbug fungus that is wreaking havoc in some hospitals. At one point, we referred to this yeast as an "organism." It is, as are all yeasts, a microorganism.

-- We've been receiving quite a few letters regarding the column about sundowning, a late-day confusion that's common among individuals with Alzheimer's disease or other types of dementia. Many of you described experiences with loved ones where symptoms similar to sundowning were caused by medication imbalances or the lingering effects of anesthesia. This is an important topic that we will take up in an upcoming column.

As ever, we'd like to thank you for your interest in, contributions to and suggestions for our columns. Every one of your letters and emails are read, and we are grateful for the time you take to write and send them.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I know that essential tremor doesn't signify a disease, but the condition is very embarrassing and sometimes limits my activities. I've tried propranolol, but it didn't help. Any suggestions?

Dear Reader: It sounds as if you understand the basics, which is great. That will help you focus your search for new options. For those who are unfamiliar with the condition, essential tremor -- unlike the tremor with Parkinson's disease -- occurs only with activity and only when holding a sustained position. In Parkinson's, the tremor occurs at rest.

Essential tremor was formerly termed "benign essential tremor," but there's nothing benign about it. For some people, it can be debilitating, affecting fine motor skills and limiting the ability to use utensils to eat, write, shave or apply makeup. A 1994 study found that 15 to 25 percent of people with essential tremor retire early as a result, and 60 percent fear looking for job or seeking a promotion because of it.

The condition is termed "essential," because the tremor is not associated with any other disease. It occurs in 5 percent of people worldwide and is more prevalent as people age. An estimated 30 to 70 percent of people with the condition have a family member who also has it, but the exact cause is unknown.

So what can you do? First, be aware that caffeine, nicotine and withdrawal from alcohol or opiates can make the tremors worse, as can stress and anxiety. Medications such as anti-depressants, amphetamines, steroids and lithium also might make essential tremor more noticeable. Alcohol may ease tremors in the short term, but patients develop a tolerance and the alcohol becomes less effective. And, as I mentioned, withdrawal leads to greater tremors.

The medication you tried, propranolol, is a beta blocker -- a blood pressure drug long used to treat essential tremor. It can be used as needed to decrease tremors in stressful situations or taken daily to suppress tremors overall. But it didn't work for you, so let's assess other options.

The anti-seizure drug primidone is also often used to ease essential tremor. It decreases nerve excitability and is as effective as propranolol, with improvement rates of about 70 percent in most people. However, many patients feel sedated, nauseated and have difficulty with balance when taking primidone. These side effects occur about 36 percent of the time.

Another anti-seizure drug, gabapentin, can also be effective, particularly at a daily dose of 1,200 mg. The problem with gabapentin is that for many people, especially the elderly, it can lead to drowsiness. It might be best to start at doses of 100 mg three times per day and increase that if necessary and if you can tolerate it. Topiramate, another anti-seizure medication, has also shown benefit in easing tremor, but it too causes drowsiness.

Also worth considering: Botox injections. Botulinum toxin can decrease head tremors, voice tremors and tremors involving the arms, but because the toxin paralyzes muscles, it can cause weakness in the injection areas.

When essential tremor is severe, surgical techniques such as deep brain stimulation may be an option. In this technique, electrodes are placed deep in an area of the brain called the thalamus and are connected to an electrical-pulse generator implanted in the chest wall.

But before you consider such a measure, start by avoiding medications and drugs that make your tremors worse, and ask your doctor about primidone or gabapentin. Also, don't give up.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)