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 guys, men. It gives them their characteristic deep voices, large muscles, and facial and body 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. It also boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have symptoms and signs 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's an underdiagnosed problem, with only about 5% of those affected receiving treatment.
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's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and why he thinks specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average man to find a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much smaller quantity 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 dismiss those"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. 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 wonder. But a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily 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 decide whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways 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 guys with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. However, there are some guys who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone for a total 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 over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines moved here with check these guys out recommendations for who should and should not click receive testosterone therapy. Is complete testosterone the ideal thing to be measuring? Or if we are measuring something different? Well, this is just another area of confusion and good debate, but I don't think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the body. But about half of their testosterone that is circulating in the bloodstream is not readily available to the cells. The biologically available portion of total testosterone is called free testosterone, and it is readily available to cells. Almost every laboratory has a blood test to measure free testosterone. Though it's only a small portion of the total, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the significance is greater than with total testosterone.
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 drop 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 average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines nevertheless say it's important to do the test in the morning, but for men 40 and over, it likely does not matter much, provided that they get their blood drawn before 5 or 6 p.m. There are some very interesting findings about diet. For instance, it seems that those who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear. In the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and 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, all the guys 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 whether it's more capable of boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes drugs such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children. What kinds of testosterone-replacement therapy can be found? * The oldest form is the injection, which we still use since it is inexpensive and since we reliably become good testosterone levels in almost everybody. The disadvantage 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 then return to research. Topical treatments help maintain a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In one 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 begin almost everyone off -- is a topical gel. According to my experience, it tends to be consumed to good degrees in about 80% to 85 percent of men, but leaves a significant number who do not absorb sufficient for this to have a positive impact. [For details on various formulations, see table ] Are there any downsides to using dyes? How long does it take for them to get the job done? Men who start using the gels have to return in to have their testosterone levels measured again to be sure they are absorbing the proper amount. Our goal is that the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within several doses. I normally measure it after two weeks, although symptoms may not alter for a month or two. |