A Harvard expert shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, distinguishing them from women. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels start to fall, by about 1 percent per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as reduced sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed issue, with only about 5 percent of those affected receiving treatment.
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 ailments and male reproductive and sexual difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and he believes experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and visit the websitepop over to this web-site diagnosisWhat signs and symptoms of low testosterone prompt the typical man to find a doctor?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally 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 dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no question. However a decrease in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if somebody has less sex drive or less interest, it is more of a struggle to get a good erection.
How can you decide if a man is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are some men who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. But no one really agrees on a few. It is similar to diabetes, in which if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. |
Is complete 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 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. However, about half of their testosterone that is circulating in the blood isn't readily available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of total testosterone is called free testosterone, and it's readily available to cells. Even though it's only a little portion of this overall, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater than with testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone treatment for men who have Therapy Isn't Suggested for men who have
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Do time of day, diet, or other factors influence testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning because levels begin to fall after 10 or 11 a.m.. However, the information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of the day. One reported no change in average testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably not enough to affect identification. Most guidelines still say it is important to do the test in the morning, however for men 40 and above, it likely doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about diet. By way of example, it seems that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear.
Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Based on the formula, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.
In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, each one the guys had heightened levels of testosteronenone reported any side effects throughout the year they were followed.
Since clomiphene citrate is not approved by the FDA for use in males, little information exists about 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 formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs like clomiphene citrate one of just a few options for men with low testosterone who want to father children.
FormulationsWhat kinds of testosterone-replacement therapy are available? *
The oldest form is an injection, which we still use because it's inexpensive and because we reliably become good testosterone levels in nearly everybody. The drawback is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also occur as blood glucose levels peak and return to research.
Topical treatments help maintain a more uniform amount of blood glucose. The first kind of topical treatment has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area on their skin. That restricts its usage.
The most widely used testosterone preparation from the United States -- and also the one I start almost everyone off with -- is a topical gel. 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 don't 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 begin using the gels have to come back in to have their own testosterone levels measured again to make sure they're absorbing the proper quantity. Our goal is that the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, in just several doses. I normally measure it after 2 weeks, even though symptoms may not change for a month or two.