A Harvard Specialist shares his Ideas 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, big 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 leads to regular erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" that makes testosterone slowly becomes less powerful, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone like lower sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance 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 receiving treatment.
Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
He's developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and he thinks specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms you could try this out and Check Out Your URL diagnosisWhat signs and symptoms of low testosterone prompt the typical person to find a doctor?
As a urologist, I have a tendency to observe men since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a lesser quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that 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 dismiss those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, it's more of a challenge to have a fantastic erection.
How do you determine if a person is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one really agrees on a few. It's similar to 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 apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. |
Is complete testosterone the right point to be measuring? Or should we be measuring something different?
Well, this is just another area of confusion and great discussion, but I don't think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. But about half of their testosterone that's circulating in the blood is not available to the cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available portion of overall testosterone is called free testosterone, and it is readily available to the cells. Almost every laboratory has a blood test to measure free testosterone. Though it's just a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater compared to testosterone.
This professional organization urges testosterone therapy for men who have both
Therapy Isn't recommended for men who have
- Prostate or breast cancer
- a nodule on the prostate which may be felt during a DRE
- a PSA greater than 3 ng/ml without further evaluation
- a hematocrit greater than 50 percent or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract infections
- class III or IV heart failure.
Do time daily, diet, or other elements influence testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning since 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 testosterone levels in men 40 and older over the course of the 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 insufficient to influence identification. 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, provided that they get their blood drawn before 5 or 6 p.m.
There are some very interesting findings about diet. By way of example, it seems that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to make any recommendations that are clear.
Within this article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending upon the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.
Within four to six weeks, each one of the guys had increased levels of testosterone; none reported any side effects throughout the year they had been followed.
Since clomiphene citrate isn't 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 is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enriches -- sperm production. That makes medication such as clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.
FormulationsWhat kinds of testosterone-replacement therapy are available? *
The oldest form is the injection, which we still use because it's cheap and since we reliably become good testosterone levels in almost everybody. The drawback is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to baseline.
Topical treatments help maintain a more uniform amount of blood glucose. The first form of topical treatment has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a reddish area in their skin. That restricts its use.
The most commonly used testosterone preparation in the United States -- and also 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 special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to good degrees in about 80% to 85% of men, but leaves a significant number who don't consume sufficient for it to have a positive effect. [For details on various formulations, see table below.]
Are there any downsides to using gels? How much time does it require them to get the job done?
Men who start using the implants need to return in to have their own testosterone levels measured again to be certain they're absorbing the proper amount. Our goal is that 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 quickly, within a few doses. I normally measure it after 2 weeks, even though symptoms may not alter for a month or two.