A Harvard Specialist shares his Ideas on testosterone-replacement therapy
An interview 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 women. It stimulates the development of the genitals , 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 testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone such as lower libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Yet it's an underdiagnosed problem, with just about 5 percent of those affected undergoing therapy.
He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his own patients, and he believes experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical man to find a doctor?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, but they are 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 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. However a decrease in orgasm intensity normally does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go along with it either, though certainly if a person has less sex drive or less interest, it's more of a challenge to get a fantastic erection.
How can you determine whether a person is a candidate for testosterone-replacement treatment?
There are just two ways that 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 those two methods is far from ideal. Generally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. But no one quite agrees on a number. It is similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. For a complete copy of look what i found the Clicking Here guidelines, log on to www.endo-society.org. |
Is total testosterone the right thing to be measuring? Or should we be measuring something different?
Well, this is another area of confusion and great debate, but I do not think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. But about half of their testosterone that is circulating in the blood is not available to the cells.
The biologically available part of total testosterone is known as free testosterone, and it is readily available to cells. Nearly every laboratory has a blood test to measure free testosterone. Though it's only a small portion of this total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the correlation is greater than with testosterone.
This professional organization recommends testosterone treatment for men who have
- Reduced levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not recommended for men who've
- Breast or prostate cancer
- a nodule on the prostate which can be felt during a DRE
- that a PSA higher than 3 ng/ml without further analysis
- that 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 daily, diet, or other elements affect testosterone levels?
For many years, the recommendation has been to get a testosterone value early in the morning since levels start to fall after 10 or 11 a.m.. But the information behind that recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature within 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 not enough to affect diagnosis. Most guidelines still say it is important to do the evaluation 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 appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been studied thoroughly enough to create any clear recommendations.
FormulationsExogenous vs. endogenous testosterone
Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Based on the formula, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.
Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the creation of natural testosterone, termed nitric oxide, in men. Within four to six weeks, all the guys had heightened levels of testosterone; none reported some side effects during 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 effects of carrying it (such as the risk of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. This makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.
What kinds of testosterone-replacement treatment are available? *
The oldest form is the injection, which we use since it is cheap and because we reliably get good testosterone levels in almost 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 return to research.
Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical treatment has been a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of people that 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 start almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. 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 absorb enough for it to have a favorable effect. [For specifics on several different formulations, see table ]
Are there any drawbacks to using gels? How long 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 actually goes up quite quickly, in just several doses. I normally measure it after 2 weeks, even although symptoms may not alter for a month or two.