A Harvard expert shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" that makes testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1 percent a year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone such as reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with only about 5 percent of those affected undergoing therapy.
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 experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his own patients, and he thinks specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical man to find a physician?
As a urologist, I tend to see men because they have sexual complaints. The main hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense climaxes, a lesser quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would usually be arousing.
The more of these symptoms you will find, the more probable it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if a person has less sex drive or less interest, it's more of a challenge to get a good erection.
How do you decide whether or not a person is a candidate for testosterone-replacement therapy?
There are two ways that we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two methods is far from ideal. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are a number of men who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one really agrees on a few. It's similar to diabetes, where if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines over here with recommendations for who should and should he has a good point not receive Home Page testosterone treatment. See"Endocrine Society recommendations summarized." Is complete testosterone the ideal point to be measuring? Or should we be measuring something different? Well, this is another area of confusion and great discussion, but I do not think it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. But about half of the testosterone that's circulating in the bloodstream is not available to the cells. The biologically available part of total testosterone is known as free testosterone, and it's readily available to cells. Even though it's just a small portion of the overall, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the significance is greater than with testosterone.
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 because levels start to drop after 10 or 11 a.m.. But 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 older over the course of the day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it's important to do the evaluation in the morning, but for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 5 or 6 p.m. There are some very interesting findings about dietary supplements. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been studied thoroughly enough to make any recommendations that are clear. In this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Depending on the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects. Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the creation of natural testosterone, also termed endogenous testosterone, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, all of the guys had increased levels of testosteronenone reported any side effects throughout the entire year they had been followed. Because clomiphene citrate isn't approved by the FDA for use in males, little information exists regarding the long-term ramifications of taking it (such as the risk of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone that wish to father children. What forms of testosterone-replacement therapy are available? * The earliest form is the injection, which we still use since it's inexpensive and because we reliably become fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and return to baseline. [See"Exogenous vs. endogenous testosterone," above.] Topical therapies 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 1 study, as many as 40 percent of men who used the patch developed a red area in their skin. That restricts its use. The most commonly used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes from miniature tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be absorbed to great degrees in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb enough for this to have a positive impact. [For details on several different formulations, see table below.] Are there any drawbacks to using dyes? How long does it require them to get the job done? Men who start using the gels have to come back in to have their own testosterone levels measured again to make certain they're absorbing the proper quantity. Our goal is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within a few doses. I usually measure it after two weeks, even though symptoms may not change for a month or two. |