Aspects For trt - What's Required

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

It might be said that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial 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 fosters the production of red blood cells, boosts mood, and aids cognition.

Over time, the testicular"machinery" which produces testosterone slowly becomes less effective, and testosterone levels begin to drop, by approximately 1% a year, beginning in the 40s. As men get in 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, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it is an underdiagnosed problem, with only about 5 percent of these affected receiving treatment.

Various studies have shown that testosterone-replacement therapy may offer a vast range of benefits for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 has developed specific experience 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 believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt that the average man to see a physician?

As a urologist, I tend to see guys since they have sexual complaints. The primary 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 should get his testosterone level checked. Men may experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.

The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.

Are not those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not exactly. 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 decrease in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to get a good erection.

How can you determine 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 signs and symptoms, and the correlation between those two methods is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have 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 believe that's a sensible guide. But no one really agrees on a number. It's similar to diabetes, in which if your fasting sugar 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 click site who should and should not receive testosterone therapy. See"Endocrine visit Society recommendations summarized."

Is total testosterone the ideal point to be measuring? Or should we be measuring something else?

This is another area of confusion and great discussion, but I do not think it's as confusing as it is apparently in 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 their testosterone that is circulating in the blood isn't available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of total testosterone is known as free testosterone, and it is readily available to the cells. Almost every laboratory has a blood test to measure free testosterone. Though it's only a small fraction of this total, 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 therapy for men who have both

Reduced levels of testosterone in the blood (less than 300 ng/dl)
symptoms of low testosterone.

Therapy Isn't recommended for men who have

Breast or prostate cancer
a nodule on the prostate which can be felt during a DRE
that a PSA higher than 3 ng/ml without additional evaluation
a hematocrit greater than 50% or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract symptoms

class III or you can look here IV heart failure.

Do time daily, diet, or other factors affect testosterone levels?

For years, the recommendation has been to get a testosterone value early in the morning because levels begin to fall after 10 or 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 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines still say it's important to do the test in the morning, however for men 40 and over, it likely doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

There are some 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 eat more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.

Exogenous vs. endogenous testosterone

In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Based on the formulation, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.

Within four to six weeks, all the guys had increased levels of testosterone; none reported any side effects during the year they were followed.

Since clomiphene citrate isn't accepted by the FDA for use in men, little information exists regarding the long-term effects 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 exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes medication such as clomiphene citrate one of just a few choices for men with low testosterone who wish to father children.

Formulations

What forms of testosterone-replacement therapy can be found? *

The earliest form is the injection, which we use because it's cheap and because we reliably become fantastic testosterone levels in nearly 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 occur as blood testosterone levels peak and then return to research. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical therapies help preserve a more uniform level of blood testosterone. The first form of topical therapy has been a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a reddish area on their skin. That restricts its usage.

The most widely used testosterone preparation from the United States -- and also the one I start almost everyone off with -- is a topical gel. According to my experience, it tends to be absorbed to great degrees in about 80% to 85% of guys, but leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For details on various formulations, see table below.]

Are there any downsides to using dyes? How long does it require them to work?

Men who begin using the gels have to come back in to have their testosterone levels measured again to be sure they're absorbing the proper amount. Our target is the mid to upper range of normal, which generally means approximately 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 although symptoms may not change for a month or two.

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