A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It might be stated 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 contributes to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower libido 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" significance low functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5% of these affected undergoing therapy.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and he thinks experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical person to see a physician?
As a urologist, I tend to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.
The more of the 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 are often treatable and reversible by decreasing testosterone levels.
Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of drugs which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if somebody has less sex drive or less attention, it is more of a struggle to get a good erection.
How do you determine if a person is a candidate for testosterone-replacement treatment?
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 these two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no signs.
Looking 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 number. It's not like diabetes, where 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 clear.
| *Note: The Endocrine Society publishes clinical practice go now guidelines additional reading with recommendations for who should and shouldn't receive testosterone therapy. Is total testosterone the right thing to be measuring? Or should we be measuring something else? This is just another area of confusion and good discussion, but I don't think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream is not readily available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Almost every lab has a blood test to measure free testosterone. Though it's just a small fraction of this overall, the free testosterone level is a fairly good indicator of low testosterone. It's not perfect, but the significance is greater compared to total testosterone. This professional organization recommends testosterone therapy for men who have
Therapy is not recommended for men who've
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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.. But the information behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of the day. One reported no change in average testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably not enough to affect diagnosis. Most guidelines nevertheless say it's important to perform the test in the morning, but for men 40 and over, 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. For instance, it seems that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to create 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. Based upon the formula, 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.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, each one of the guys had increased levels of testosterone; none reported some side effects throughout the year they had been followed.
Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of taking it (including the probability of developing prostate cancer) or whether it is more capable of boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enhances -- sperm production. This makes medication like clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.
FormulationsWhat kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we still use since it is inexpensive and because we faithfully become fantastic testosterone levels in nearly everybody. The disadvantage is that a man should 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 level of blood testosterone. The first kind of topical treatment has been a patch, but it has a quite high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area in their skin. That restricts its usage.
The most widely used testosterone preparation from the United States -- and also the one I begin almost everyone off with -- 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 consumed to great degrees in about 80% to 85 percent of guys, but leaves a significant number who do not consume sufficient for this to have a favorable impact. [For details on several different formulations, see table ]
Are there any drawbacks to using gels? How long does it take for them to work?
Men who start using the gels have to come back in to have their testosterone levels measured again to make sure they're absorbing the right amount. 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 actually goes up quite quickly, within a few doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two.