A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from girls. It stimulates the development of the genitals , 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" that makes testosterone gradually 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 like reduced 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" significance low working and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed issue, with just about 5% 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 diseases and male sexual and reproductive difficulties. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his own patients, and he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms get moreClick Here and article diagnosisWhat signs and symptoms of low testosterone prompt that the typical man to see a doctor?
As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much smaller amount of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something that would usually be arousing.
The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often dismiss these"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 quite a few drugs which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount 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 ordinarily go along with it , though surely if somebody has less sex drive or less interest, it is more of a challenge to have a good erection.
How can you determine if a man is a candidate for testosterone-replacement treatment?
There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. However, no one really agrees on a number. It is similar to diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. |
Is complete testosterone the ideal thing to be measuring? Or if we are measuring something different?
Well, this is another area of confusion and good discussion, but I don't think 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 the testosterone in the body. However, about half of their testosterone that's circulating in the bloodstream isn't readily available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Though it's only a small 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 total testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone therapy for men who have both Therapy Isn't recommended for men who have
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Do time of day, diet, or other elements influence testosterone levels?
For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to drop after 10 or 11 a.m.. But the information behind this recommendation were attracted to healthy young men. Two recent studies showed 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 influence diagnosis. Most guidelines still say it's important to do the test in the morning, but for men 40 and above, it probably doesn't matter much, as long as they obtain their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about dietary supplements. By way of instance, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been studied thoroughly enough to make any clear recommendations.
In the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced 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, and additional side effects.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, each one of the men had increased levels of testosterone; none reported any side effects throughout the 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 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. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone who wish to father children.
FormulationsWhat kinds of testosterone-replacement therapy can be found? *
The oldest form is an injection, which we use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to research.
Topical therapies help preserve a more uniform level of blood glucose. 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 in their skin. That limits its use.
The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes from tiny tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of guys, but that leaves a significant number who don't consume enough for this to have a favorable effect. [For details on various formulations, see table ]
Are there any downsides to using gels? How much time does it require them to work?
Men who begin using the gels have to come back in to have their own testosterone levels measured again to make certain they are absorbing the right quantity. Our goal is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I normally measure it after two weeks, even though symptoms may not change for a month or two.