A Harvard expert shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
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 development of the genitals , 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 about 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like reduced libido and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with just about 5 percent of these affected undergoing therapy.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face.
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 has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and he believes experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the typical man to see a physician?
As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a feeling of numbness in the penis 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 often dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications that may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally doesn't go along with therapy for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How do you decide whether or not 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 one is by characteristic symptoms and signs, and the correlation between these two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations summarized." this content For a complete copy of the instructions, view it now log on to look at this now www.endo-society.org. |
Is total testosterone the ideal point to be measuring? Or should we be measuring something else?
This is another area of confusion and good debate, but I do not 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 overall testosterone, or all of the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream is not readily available to cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available part of total testosterone is known as free testosterone, and it is readily available to cells. Though it's only a little fraction of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone treatment for men who have Therapy Isn't Suggested for men who've
|
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 drop after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies demonstrated 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 p.m. Between 2 and 6 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect diagnosis. Most guidelines still say it's important to perform 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. For example, it appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.
Exogenous vs. endogenous testosteroneIn this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Depending upon the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects. 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. Because clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of taking it (including the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes medication 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 can be found? * The oldest form is the injection, which we still use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and return to research. Topical therapies help maintain a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area in their skin. That limits its usage. The most commonly used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes from tiny 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 that leaves a significant number who don't absorb sufficient for it to have a favorable effect. [For details on various formulations, see table ] Are there any downsides to using gels? How long does it require them to work? Men who start using the implants need to return in to have their testosterone levels measured again to make certain they are absorbing the right amount. Our goal is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, in just a few doses. I usually measure it after two weeks, even although symptoms may not change for a month or two. |