A Harvard expert shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It might be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" that makes testosterone gradually becomes less powerful, and testosterone levels begin to drop, by about 1% per year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone such as reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed problem, with only about 5% of these affected receiving treatment.
Various studies have shown that testosterone-replacement therapy may provide a vast selection of benefits for men with hypogonadism, such as 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 may 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 specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and he thinks specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average man to see a physician?
As a urologist, I tend to observe men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a much lesser amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would usually be arousing.
The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if somebody has less sex drive or less attention, it is more of a struggle to have a good erection.
How can you decide whether a man is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether someone has reduced 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 ideal. Normally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are a number of guys 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 total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a few. It is 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 apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and find out this here should not receive testosterone therapy. See"Endocrine Society recommendations summarized." For a complete copy of the instructions, log on to www.endo-society.org. |
Is total testosterone the ideal thing to be measuring? Or should we be measuring something else?
Well, this is just another area of confusion and good debate, but I don't think that it's as confusing as it appears to be in the literature. When most doctors 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 is circulating in the blood is not readily available to cells.
The available part of total testosterone is called free testosterone, and it is readily available to the cells. Though it's just a small portion of the overall, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the correlation is greater than with testosterone.
Endocrine Society recommendations summarizedThis professional organization recommends testosterone therapy for men who have both
Therapy Isn't Suggested for men who've
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Do time of day, diet, or other factors influence testosterone levels?
For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or 11 a.m.. But the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature within 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%, a small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to do the evaluation in the morning, however for men 40 and over, it probably doesn't matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about dietary supplements. By way of instance, it appears 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.
In this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Depending upon the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects.
Within four to six months, all of the men had increased levels of testosteronenone reported some side effects throughout the entire year they had been followed.
Since clomiphene citrate isn't approved by the FDA for use in males, little information exists about the long-term effects of carrying it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few choices for men with low testosterone that want to father children.
What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we use since it is inexpensive and because we reliably become fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every few weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to research.
Topical treatments help preserve a more uniform level of blood glucose. The first form of topical therapy has been a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a red area on their skin. That restricts its usage.
The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes in miniature tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be absorbed to good degrees in about 80% to 85% of guys, but leaves a significant number who don't absorb sufficient for this to have a favorable impact. [For details on various formulations, see table ]
Are there any downsides to using dyes? How long does it take for them to get the job done?
Men who start using the gels have to come back in to have their own testosterone levels measured again to make sure they're absorbing the right quantity. Our goal is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, within a few doses. I normally measure it after two weeks, though symptoms may not alter for a month or two.