A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, big 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 leads to normal erections. Additionally, it boosts the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" that produces testosterone gradually becomes less effective, and testosterone levels start to fall, by approximately 1 percent a year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like reduced sex drive 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 functioning 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 issue, with just about 5 percent of these affected undergoing therapy.
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 reproductive and sexual problems. He's developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and why he believes experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical person to see a physician?
As a urologist, I tend to observe men since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much smaller amount of fluid from 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 you will find, the more probable it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications which may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if a person has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How can you determine if a man is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from ideal. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking 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's a sensible guide. However, no one really agrees on a number. 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 publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations summarized." review For a complete copy of these instructions, log on to www.endo-society.org. |
Is complete testosterone the right thing to be measuring? Or should we be measuring something different?
This is just 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 physicians learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of the testosterone that's circulating in the blood is not readily available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the correlation is greater compared to total testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone therapy for men who have Therapy Isn't recommended for men who have
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Do time daily, diet, or other elements affect testosterone levels?
For many years, the recommendation was to get a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. However, the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of the day. One reported no change in typical testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably insufficient to influence identification. Most guidelines nevertheless say it's important to do the evaluation in the morning, however for men 40 and above, it probably does not matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about diet. 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 researched thoroughly enough to create any clear recommendations.
Exogenous vs. endogenous testosteroneIn this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Depending on the formula, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects. 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, each one the guys had increased levels of testosteronenone reported some side effects throughout the entire year they had been followed. Since clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone that wish to father children. |
What kinds of testosterone-replacement treatment can be found? *
The earliest form is the injection, which we use because it is inexpensive and because we reliably get fantastic testosterone levels in almost everybody. The drawback is that a person should come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and then return to baseline.
Topical treatments help preserve a more uniform amount of blood testosterone. The first form of topical therapy has been a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of men who used the patch developed a reddish area in their skin. That restricts its usage.
The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. The gel comes in tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be consumed to great levels in about 80% to 85% of guys, but leaves a substantial number who do not consume enough for it to have a positive impact. [For details on various formulations, see table below.]
Are there any downsides to using dyes? How long does it take for them to get the job done?
Men who begin using the gels have to come back in to have their own testosterone levels measured again to be sure they are absorbing the proper amount. 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 blood actually goes up quite fast, within a few doses. I normally measure it after 2 weeks, although symptoms may not alter for a month or two.