Explaining No-Hassle testosterone therapy Systems

A Harvard expert shares his Ideas on testosterone-replacement therapy

A meeting with Abraham Morgentaler, M.D.

It might be stated that testosterone is the thing that makes guys, 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 , plays a role in sperm production, fuels libido, and contributes to normal erections. It also boosts the creation of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" that produces testosterone slowly becomes less powerful, and testosterone levels begin to fall, by approximately 1% per year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like lower sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed problem, with just about 5% of those affected receiving treatment.

Various studies have revealed that testosterone-replacement therapy may provide a wide range of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production.

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 expertise 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 believes specialists should rethink the possible connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the typical person to see a doctor?

As a urologist, I have a tendency to observe guys since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something that would normally be arousing.

The more of the symptoms you will find, the more probable it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, however, they're 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 exactly. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually does not go together 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 attention, it's more of a challenge to have a fantastic erection.

How do you determine whether a man is a candidate for testosterone-replacement therapy?

There are just two ways we determine whether somebody 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. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. However, there are some guys who have low levels of testosterone in their blood and have no signs.

Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that is a sensible guide. But no one quite agrees on a number. It is not like diabetes, in which if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.

*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. Watch"Endocrine a fantastic read Society recommendations summarized." For a visit complete copy of the instructions, log on to www.endo-society.org.

Is complete testosterone the right point to be measuring? Or should we be 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 in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of their testosterone that's circulating in the blood is not available to cells.

The 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 just a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the correlation is greater than with testosterone.

This professional organization recommends testosterone therapy for men who have both

Low levels of testosterone in the blood (less than 300 ng/dl)
symptoms of low testosterone.

Therapy Isn't recommended for men who've

Breast or prostate cancer
a nodule on the prostate which can be felt during a DRE
a PSA higher than 3 ng/ml without further evaluation
a hematocrit greater than 50 percent or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract infections

class III or IV heart failure.

Do time of day, diet, or other factors influence testosterone levels?

For many years, the recommendation has been to get a testosterone value early in the morning since levels begin to drop after 10 or even 11 a.m.. However, the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of this day. One reported no change in average testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably insufficient to affect diagnosis. Most guidelines nevertheless 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 6 or 5 p.m.

There are some rather interesting findings about dietary supplements. By way of example, it appears that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to make any clear recommendations.

Exogenous vs. endogenous testosterone

In this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based on the formula, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and 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 weeks, all of the men had increased levels of testosterone; none reported some side effects throughout the entire year they had been followed.

Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists regarding the long-term ramifications of carrying it (such as the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who want to father children.

Formulations

What kinds of testosterone-replacement treatment can be found? *

The earliest form is an injection, which we still 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 couple of weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and then return to baseline.

Topical treatments help preserve a more uniform level of blood glucose. The first kind of topical therapy has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area in their skin. That limits its usage.

The most widely used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it has a tendency to be absorbed to great levels in about 80% to 85 percent of guys, but that leaves a substantial number who don't absorb enough for this to have a positive impact. [For specifics on several different formulations, see table ]

Are there any downsides to using gels? 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 testosterone levels measured again to be certain they're absorbing the proper quantity. Our target is the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just several doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two.

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