A Harvard expert shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It might be stated that testosterone is the thing that makes guys, guys. 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. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" which produces testosterone slowly 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 libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as 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 just about 5 percent 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 may 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 ailments and male reproductive and sexual problems. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he thinks experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.
Symptoms Read More Here and Websitelook at this site diagnosisWhat signs and symptoms of low testosterone prompt the typical man to see a physician?
As a urologist, I tend to see guys because they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.
The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How do you determine if a person is a candidate for testosterone-replacement therapy?
There are just two ways that we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two methods is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are a number of guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. |
Is total testosterone the ideal point to be measuring? Or should we be measuring something else?
This is just another area of confusion and great debate, but I do not think that it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't available to the cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available part of total testosterone is called free testosterone, and it's readily available to the cells. Though it's only a little portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone treatment for men who have Therapy is not Suggested for men who've
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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 fall after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older over 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 sum, and probably insufficient to affect diagnosis. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and above, it probably doesn't matter much, provided that they obtain their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about diet. For example, it seems that those who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been studied thoroughly enough to make any clear recommendations.
Exogenous vs. endogenous testosteroneIn this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based upon the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects. Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the production of natural testosterone, known as nitric oxide, in men. Within four to six months, all the guys had increased levels of testosterone; none reported some side effects during the year they had been followed. Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of carrying it (including the probability of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone that want to father children. What kinds of testosterone-replacement therapy can be found? * The oldest form is the injection, which we still use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood glucose levels peak and return to research. [See"Exogenous vs. endogenous testosterone," above.] Topical treatments help maintain a more uniform amount of blood testosterone. The first form of topical treatment was a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a red area on their skin. That restricts its use. The most widely used testosterone preparation from the United States -- and the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it tends to be consumed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb enough for this to have a positive effect. [For details on several different formulations, see table below.] Are there any drawbacks to using dyes? How much time does it take for them to work? Men who begin using the implants need to return in to have their own testosterone levels measured again to make certain they are absorbing the right quantity. Our goal is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just a few doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two. |