A Harvard expert shares his Ideas on testosterone-replacement Treatment
It might be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial 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, 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 symptoms and signs are often called hypogonadism ("hypo" significance low functioning and"gonadism" referring 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 issue, with only about 5 percent of those affected undergoing therapy.
Various studies have shown that testosterone-replacement therapy can offer a vast range of advantages 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 problems. He has 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 patients, and why he thinks specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical man to find a doctor?
As a urologist, I tend to observe men since they have sexual complaints. The main hallmark of low testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men may experience other symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a much smaller quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.
The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.
Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may lessen sex drive, including the BPH medication 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 does not go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it either, though surely if a person has less sex drive or less attention, it is more of a challenge to get a good erection.
How do you decide if a man is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two approaches is far from perfect. 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 symptoms.
Looking purely 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 is a sensible guide. However, no one really 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 clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. See"Endocrine Society recommendations summarized." For Full Report a you could check here complete copy of the guidelines, log on to www.endo-society.org. |
Is total testosterone the right thing to be measuring? Or should we be measuring something different?
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 heard about overall testosterone, or all of the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of overall testosterone is called free testosterone, and it's readily available to the cells. Though it's only a small portion of this 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 recommends testosterone therapy for men who have
Therapy Isn't Suggested for men who've
- Prostate or breast cancer
- a nodule on the prostate that can be felt during a DRE
- that a PSA higher than 3 ng/ml without further analysis
- that a hematocrit greater than 50 percent 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 elements influence testosterone levels?
For many years, the recommendation has been to get a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose 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 percent, a small amount, and probably not enough to affect identification. Most guidelines still say it is important to do the test in the morning, however for men 40 and above, it likely does not matter much, provided that they get their blood drawn before 6 or 5 p.m.
There are some rather 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 researched thoroughly enough to make any clear recommendations.
Exogenous vs. endogenous testosteroneIn the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending upon the formulation, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased 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 three or more months. Within four to six weeks, each one of the guys had heightened levels of testosteronenone reported some side effects during the entire year they were followed. Since clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term effects of carrying it (including the probability of developing prostate cancer) or if it's more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. That 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 therapy are available? *
The earliest form is an injection, which we use since it is cheap and because we faithfully get fantastic testosterone levels in almost everybody. The disadvantage is that a man should come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to research.
Topical therapies help maintain a more uniform amount of blood testosterone. The first kind 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 people that used the patch developed a reddish area in their skin. That limits its use.
The most commonly used testosterone preparation in the United States -- and the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. According to my experience, it has a tendency to be absorbed to good levels 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 ]
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 the mid to upper assortment 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 normally measure it after 2 weeks, even although symptoms may not alter for a month or two.