A Harvard expert shares his thoughts on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It could be said that testosterone is the thing that 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 at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" that produces testosterone slowly becomes less effective, and testosterone levels begin to drop, by about 1% per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms 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 is an underdiagnosed issue, with only about 5 percent of those affected receiving treatment.
Various studies have shown that testosterone-replacement therapy may provide a wide selection of benefits for men with hypogonadism, such as improved 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 ailments and male reproductive and sexual difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average person to see a physician?
As a urologist, I have a tendency to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of ejaculation, and a feeling of numbness in the penis 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 tend to discount those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go together with it , though certainly if a person has less sex drive or less attention, it is more of a challenge to get a good erection.
How can you decide if a man is a candidate for testosterone-replacement therapy?
There are just two ways 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 those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. But there are some men who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. But no one quite agrees on a few. It is similar to diabetes, in which if your fasting glucose is above 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 recommends clinical practice guidelines with recommendations for who should click for info and should view publisher site not receive testosterone treatment. Is complete testosterone the ideal point to be measuring? Or if we are measuring something different? This is just another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the blood is not available to the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available part of total testosterone is called free testosterone, and it's readily available to cells. Though it's just a small fraction of the overall, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the significance is greater compared to total testosterone.
Do time of day, diet, or other elements influence testosterone levels? For years, the recommendation was to receive a testosterone value early in the morning because levels begin to fall after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of the day. One reported no change in typical 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 perform the test in the morning, however for men 40 and above, it probably does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m. There are a number of very interesting findings about dietary supplements. By way of example, it seems that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to make any recommendations that are clear. Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending upon the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced 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 months, all the guys had increased levels of testosterone; none reported some side effects during the entire year they had been followed. Because clomiphene citrate isn't accepted 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's more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enhances -- sperm production. This makes medication like clomiphene citrate one of just a few options for men with low testosterone who want to father children. What kinds of testosterone-replacement therapy are available? * The earliest form is the injection, which we use since it's inexpensive and since we faithfully become good testosterone levels in nearly everybody. The drawback is that a person needs to come in every few 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 preserve a more uniform amount of blood testosterone. The first form of topical therapy was a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area on their skin. That limits 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. There are two brands: AndroGel and Testim. Based on my experience, it has a tendency to be consumed to great degrees in about 80% to 85% of men, but that leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For details on several different formulations, see table ] Are there any downsides to using dyes? How much time does it require them to get the job done? Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper quantity. Our goal is that the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just a few doses. I usually measure it after 2 weeks, though symptoms may not change for a month or two. |