A Harvard expert shares his thoughts on testosterone-replacement Treatment
It might be stated that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by approximately 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like lower sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with just about 5 percent of those affected receiving treatment.
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 sexual and reproductive difficulties. He's developed specific expertise in treating lower 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 signs and symptoms of low testosterone prompt the typical man to find a physician?
As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more trouble 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 which 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 dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, it's more of a challenge to get a good erection.
How do you determine whether a man is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether someone 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 ideal. Normally guys with the lowest testosterone have the most symptoms and guys with highest 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 numbers, The Endocrine Society* believes low testosterone for a total testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really agrees on a few. It's similar to diabetes, in which if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive Check Out Your URL testosterone treatment. Watch"Endocrine Society recommendations summarized." For linked here a complete copy of these guidelines, log next page on to www.endo-society.org. Is complete testosterone the right point to be measuring? Or if we are measuring something else? This is another area of confusion and good debate, but I don't think that it's as confusing as it appears to be from 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 bloodstream isn't available to cells. The available part of overall testosterone is known as free testosterone, and it's readily available to cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's just a little fraction of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the significance is greater than with total testosterone. This professional organization urges testosterone treatment for men who have both Therapy Isn't Suggested for men who have
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Do time daily, diet, or other elements influence testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature within the course of this day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and over, it likely does not 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 diet. For example, it seems that those 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 recommendations that are clear.
Exogenous vs. endogenous testosteroneWithin the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Depending on the formulation, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional 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 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 isn't approved by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (including 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 drugs 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 oldest form is an injection, which we use since it is cheap and since we reliably get good testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical treatments help preserve a more uniform amount of blood glucose. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area on their skin. That limits its use.
The most commonly used testosterone preparation in the United States -- and the one I begin almost everyone off -- is a topical gel. The gel comes in miniature tubes or within a unique 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 levels in about 80% to 85 percent of guys, but leaves a significant number who don't absorb enough for this to have a favorable impact. [For specifics on various formulations, see table below.]
Are there any downsides to using dyes? How much time does it take for them to work?
Men who begin using the implants need to return in to have their testosterone levels measured again to be certain they're absorbing the right quantity. Our target is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I normally measure it after 2 weeks, although symptoms may not change for a month or two.