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A Harvard expert shares his thoughts on testosterone-replacement therapy

It could be said that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" that produces testosterone slowly becomes less effective, and testosterone levels start to drop, by about 1 percent a year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with just about 5% of these affected undergoing therapy.

But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. Much of the current debate focuses on the long-held belief that testosterone can stimulate prostate cancer.

Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate diseases and male sexual and reproductive problems. He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he thinks experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt that the typical man to see a physician?

As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something which would usually be arousing.

The more of these symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.

Aren't those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of medications which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally does not go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if a person has less sex drive or less interest, it's more of a struggle to have a fantastic erection.

How do you determine whether or not a person is a candidate for testosterone-replacement treatment?

There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are a number of guys 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 believe that is a sensible guide. However, no one really agrees on a few. It is similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for view website who should and shouldn't receive testosterone therapy.

Is total testosterone the ideal point to be measuring? Or if we are measuring something different?

This is just another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. However, about half of their testosterone that is circulating in the blood isn't readily available to cells.

The biologically available part of overall testosterone is known as free testosterone, and it is readily available to cells. Nearly every laboratory has a blood test to measure free testosterone. Though it's just a small fraction of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the significance is greater compared to testosterone.

This professional organization recommends testosterone therapy for men who have both

  • Reduced levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy is not recommended for men who have

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • that a PSA higher than 3 ng/ml without additional evaluation
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III click this site or IV heart failure.

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

    For years, the recommendation has been to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. However, the information behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature within the course of the day. One reported no change in average testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a small amount, and probably not enough to affect identification. Most guidelines still say it is important to perform the test in the morning, however for men 40 and over, it probably does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

    There are some rather interesting findings about diet. For instance, it appears that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.

    Within this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based on the formula, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

    Within four to six months, all the men had increased levels of testosterone; none reported some side effects during the entire year they were followed.

    Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enhances -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.

    What forms of testosterone-replacement treatment can be found? *

    The oldest form is an injection, which we use because it is cheap and because we reliably become fantastic testosterone levels in nearly everybody. The drawback is that a person needs to come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood glucose levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help maintain a more uniform level of blood testosterone. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area in their skin. That limits its use.

    The most commonly used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be consumed to great levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb sufficient for this to have a favorable impact. [For details on several different formulations, see table ]

    Are there any downsides to using dyes? How long does it take for them to work?

    Men who start using the gels have to return in to have their own testosterone levels measured again to be certain they are absorbing the proper quantity. Our goal is that the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in 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.

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