A Harvard expert shares his thoughts on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It could 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, differentiating them from girls. It stimulates the growth 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 assists cognition.
Over time, the testicular"machinery" which produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by approximately 1% per year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with just about 5 percent of those affected receiving treatment.
Studies have shown that testosterone-replacement therapy can offer a wide range of benefits for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production.
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 link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the typical person to find a physician?
As a urologist, I have a tendency to see guys because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser quantity of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something which would normally be arousing.
The more of the symptoms you will find, the more likely 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.
Are not those the 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, 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 doesn't go along with therapy for BPH. Erectile dysfunction does not usually go together with it either, though certainly if somebody has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How do you decide whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether someone has low testosterone. One is a blood test and the other 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 maximum testosterone possess the least. However, there are some guys who have reduced levels of testosterone in their blood and have no signs.
Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. However, no one quite agrees on a few. It is not like diabetes, in which if your fasting glucose 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 publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. |
Is complete testosterone the right point to be measuring? Or if we are measuring something else?
This is just another area of confusion and great debate, but I don't think that it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the human body. But about half of the testosterone that is circulating in the bloodstream is not readily available to the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of total testosterone is known as free testosterone, and it is readily available to the cells. Though it's only a small fraction of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the significance is greater compared to total testosterone.
This professional organization urges testosterone treatment for men who have both
Therapy Isn't recommended for men who've
- Breast or prostate cancer
- a nodule on the prostate which may be felt during a DRE
- a PSA higher than 3 ng/ml without additional analysis
- that a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract infections
- class III or IV click this heart why not find out more failure.
Do time of day, diet, or other factors influence testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning because 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 over the course of this day. One reported no change in average testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably not enough to affect identification. Most guidelines nevertheless 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 get 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 appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to create any clear recommendations.
In the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Based upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, all the guys had heightened levels of testosterone; none reported some side effects throughout the entire year they had been followed.
Since clomiphene citrate isn't accepted by the FDA for use in men, little information exists about the long-term effects of carrying it (such as the risk of developing prostate cancer) or if it's more capable of boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. This makes medication like clomiphene citrate one of just a few choices for men with low testosterone who want to father children.
FormulationsWhat kinds of testosterone-replacement therapy can be found? *
The earliest form is the injection, which we use since it is cheap and since we faithfully become good testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every couple of weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and then 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 very large rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a red area in their skin. That restricts its use.
The most widely used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes in miniature tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to great levels in about 80% to 85 percent of guys, but leaves a significant number who don't consume enough for this to have a positive impact. [For details on several different formulations, see table below.]
Are there any downsides to using gels? How long 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 be certain they're absorbing the right quantity. Our target is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, in just a few doses. I usually measure it after 2 weeks, though symptoms may not alter for a month or two.