A Harvard expert shares his thoughts on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. It also boosts the production of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which produces testosterone slowly becomes less effective, and testosterone levels begin to drop, by about 1 percent a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower libido and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called 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 issue, with only about 5% of those affected receiving treatment.
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 experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.
Symptoms recommended you readyou can try here and pop over to this web-site diagnosisWhat symptoms and signs of low testosterone prompt the average person to see a doctor?
As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a lesser amount 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 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, but they're often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if somebody has less sex drive or less interest, it is more of a challenge to have a good erection.
How do you decide whether or not a man is a candidate for testosterone-replacement treatment?
There are just two ways that 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 perfect. Normally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. However, there are some men who have reduced 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 sensible guide. But no one really agrees on a number. It's similar to diabetes, where 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 who should and should not receive testosterone treatment. See"Endocrine Society recommendations summarized." |
Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?
This is another area of confusion and great debate, but I do not think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the human body. However, about half of the testosterone that's circulating in the blood isn't readily available to the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of total testosterone is known as free testosterone, and it is readily available to cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater than with total testosterone.
This professional organization urges testosterone therapy for men who have both
- Low levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not Suggested for men who've
- Breast or prostate 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% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III or IV heart failure.
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 11 a.m.. But the data 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 until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to influence identification. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and over, it likely doesn't 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 individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been studied thoroughly enough to create any clear recommendations.
In this article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Depending on the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.
Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the production of natural testosterone, termed endogenous testosterone, in men. Within four to six weeks, each one of the guys had increased levels of testosterone; none reported some side effects throughout the year they had been followed.
Because clomiphene citrate is not approved by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it is more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication like clomiphene citrate one of just a few options for men with low testosterone who wish to father children.
What kinds of testosterone-replacement treatment are available? *
The oldest form is an injection, which we still use since it's inexpensive and because we reliably get fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline.
Topical treatments help maintain a more uniform amount of blood glucose. The first form of topical therapy was a patch, but it has a very high rate of skin irritation. In one 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 widely used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. The gel comes in miniature tubes or in a unique 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 substantial number who don't absorb sufficient for this to have a favorable impact. [For details on various formulations, see table below.]
Are there any downsides to using gels? How long does it take for them to work?
Men who begin using the implants need to return in to have their testosterone levels measured again to be certain they're absorbing the proper quantity. Our goal is the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, in just several doses. I usually measure it after 2 weeks, though symptoms may not change for a month or two.