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Why Do Steroids Cause Psychosis?

**1. Sexual Function Assessment in Brain‑Tumor Patients**

| Domain | What to Evaluate | Why It Matters |
|--------|------------------|---------------|
| **Physical Functioning** | • Erectile function (ED), ejaculatory issues, vaginal lubrication
• Hormonal status: testosterone, estradiol, LH/FSH, prolactin | Tumors or treatment can disrupt neuro‑endocrine pathways → impotence, anorgasmia |
| **Psychological / Cognitive Impact** | • Mood (depression/anxiety), self‑esteem, body image
• Cognitive deficits: memory, attention, executive function | Neurocognitive decline affects sexual desire and performance; mood disorders further impair libido |
| **Relationship Dynamics** | • Partner communication, intimacy expectations, relational satisfaction | Relationship strain can exacerbate sexual dysfunction or conversely be a source of support |
| **Treatment‑Related Factors** | • Surgical side‑effects (nerve damage), radiotherapy-induced fibrosis, chemotherapy neurotoxicity
• Hormonal therapies altering testosterone/estrogen levels | Physical changes directly influence sexual function; endocrine shifts alter libido and erectile capacity |

---

## Practical Clinical Recommendations

| Step | Action | Key Points |
|------|--------|------------|
| 1 | **Initial Screening** | • Use brief questionnaires (e.g., PHQ‑2 for depression, IIEF‑5 for erectile dysfunction) at each visit.
• Ask about sexual activity and satisfaction in a non‑judgmental way. |
| 2 | **Detailed History** | • Document frequency, type of intercourse, use of lubricants/condoms, pain or dyspareunia, urinary symptoms, medication side‑effects. |
| 3 | **Physical & Laboratory Review** | • Assess prostate size (digital rectal exam), PSA trends.
• Check testosterone, LH/FSH if erectile dysfunction is persistent despite therapy. |
| 4 | **Address Modifiable Factors** | • Encourage weight loss, exercise, smoking cessation.
• Discuss sexual positioning to reduce pain for the woman. |
| 5 | **Therapeutic Interventions** | - **Vaginal lubricants/creams**: non‑ionic, preservative‑free options.
- **Topical estrogen (for post‑menopausal)**: short course if symptomatic.
- **PDE‑5 inhibitors**: titrate dose; start low to assess tolerance.
- **Pelvic floor physical therapy**: can improve arousal and reduce pain. |
| 6 | **Follow‑Up Plan** | - Reassess after 4–6 weeks of PDE‑5 inhibitor use and lubricant regimen.
- If adequate response, maintain current dosing; if insufficient, consider dose escalation or alternative agents (e.g., vardenafil).
- If still inadequate, evaluate for underlying endocrine disorders or psychological factors. |

---

## 3. Evaluation & Management of Low Testosterone in the Context of Hirsutism

| Step | Action | Rationale |
|------|--------|-----------|
| **Baseline labs** | • Serum total testosterone (morning 7–10 am)
• SHBG, albumin
• LH, FSH
• Estradiol
• Prostate‑specific antigen (PSA) if >50 yr or risk factors | Confirm androgen excess, rule out secondary causes. |
| **Interpretation** | • Low testosterone with normal/low SHBG suggests primary hypogonadism
• Elevated LH indicates primary testicular failure
• Normal LH/FSH may indicate secondary hypogonadism (pituitary/hypothalamic) | Tailor therapy accordingly. |
| **Baseline labs before therapy** | • CBC, CMP, lipid panel, fasting glucose, HbA1c, testosterone (morning), PSA (if >50 yr) | Establish baseline for monitoring. |

---

## 4. Treatment Algorithm

### Step‑by‑Step Decision Tree

```
START
|
|---> Check eligibility:
• No contraindications (no severe liver disease, untreated hypertension, etc.)
• Informed consent obtained.
|
|---> Baseline labs:
• CBC, CMP, fasting lipids, fasting glucose/HbA1c, testosterone (morning), PSA (if >50).
|
|---> Select anabolic agent:
|--- Option A: Enobosarm (oral) – 2.5–10 mg daily
|--- Option B: SARMs via injection (e.g., Ostarine 25 mg IM weekly)
|
|---> Determine dosing schedule based on product availability and patient's preference.
|
|---> Initiate therapy:
|--- Educate patient on potential side effects:
• Mild liver enzyme elevations
• Transient lipid changes (increase LDL, decrease HDL)
• Mood alterations
• Possible gynecomastia (rare)
|
|---> Monitoring plan:
|--- Baseline labs: LFTs, fasting lipids, CBC, testosterone levels.
|--- Repeat labs at 4–6 weeks post-initiation, then every 3 months.
|--- Adjust dose or discontinue if AST/ALT > 2× ULN or lipid abnormalities exceed thresholds.
|
|---> Duration:
|--- Use for the shortest effective period (e.g., 12–24 weeks).
|--- After completion, reassess motivation and consider alternative interventions.
|
|---> Safety considerations:
|--- Avoid use in individuals with uncontrolled hypertension, active liver disease,
or those on medications metabolized by CYP3A4 that could interact with ketone metabolism.
|--- Monitor for signs of ketoacidosis (e.g., nausea, vomiting, abdominal pain).
|
END
```

**Key Points:**

- **Ketone supplements may alter brain fuel availability and influence motivation.**
- **Safety hinges on monitoring metabolic status and avoiding high‑dose or prolonged use.**
- **A structured protocol can help balance potential benefits against risks for those seeking to enhance task engagement.**

This approach offers a systematic way to evaluate whether ketone supplementation could be a viable tool for improving sustained effort in demanding cognitive tasks, while ensuring participant safety.