A Harvard expert shares his thoughts on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that produces testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone like lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called 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 risks 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 difficulties. He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and why he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms over herecheck it out and pop over to this web-site diagnosisWhat signs and symptoms of low testosterone prompt the typical person to find a doctor?
As a urologist, I tend to observe guys since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller 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 there are, 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're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications which may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually 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 attention, it's more of a struggle to get a fantastic erection.
How do you determine if or not 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 symptoms and signs, and the correlation between these two methods is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. However, there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one really agrees on a number. It is similar to diabetes, where if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. |
Is complete 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 closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available part of overall testosterone is known as free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Though it's just 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 recommended for men who have
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Do time daily, 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 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 glucose levels in men 40 and mature within the course of this day. One reported no change in typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it's important to perform the test in the morning, but for men 40 and above, it probably does not matter much, as long as they obtain their blood drawn before 6 or 5 p.m.
There are some very interesting findings about diet. For example, 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 researched thoroughly enough to create any recommendations that are clear.
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Based upon the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.
In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all the men had increased levels of testosterone; none reported some side effects throughout the year they had been followed.
Since clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of taking it (such as the risk of developing prostate cancer) or if it's more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone that want to father children.
FormulationsWhat 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 good testosterone levels in almost everybody. The disadvantage is that a man should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to baseline.
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 usage.
The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes in 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 do not consume enough for this to have a positive impact. [For specifics on several different formulations, see table below.]
Are there any downsides to using gels? How much time does it require them to work?
Men who begin using the gels have to return in to have their own testosterone levels measured again to make certain they're absorbing the proper quantity. Our target is that the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I normally measure it after 2 weeks, though symptoms may not alter for a month or two.