A Harvard expert shares his thoughts on testosterone-replacement Treatment
It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, big 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 such as 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 called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with only about 5 percent of these affected undergoing therapy.
Various studies have revealed that testosterone-replacement therapy may offer a wide range of advantages for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 sexual and reproductive problems. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and he believes specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms why not find out more and Full Reportwebsite here diagnosisWhat signs and symptoms of low testosterone prompt the typical man to see a physician?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other man 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 amount 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 discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go along with it , though certainly if somebody has less sex drive or less attention, it is more of a challenge to have a good erection.
How can you decide if or not a man is a candidate for testosterone-replacement treatment?
There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between these two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and men with maximum 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 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 number. It is not like diabetes, where if your fasting sugar is over a certain level, they'll 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 should not receive testosterone therapy. |
Is total testosterone the ideal point to be measuring? Or should we be measuring something else?
Well, this is another area of confusion and great discussion, but I don't think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream is not readily available to cells. It's tightly 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 just a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone treatment for men who have Therapy is not recommended for men who've
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Do time of day, diet, or other elements affect testosterone levels?
For years, the recommendation has been to get a testosterone value early in the morning because levels start to fall 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 over 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%, a small sum, and probably not enough to affect identification. Most guidelines nevertheless say it's 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 some very interesting findings about diet. By way of instance, it appears that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.
Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending upon the formula, 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.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all of the guys had increased levels of testosterone; none reported some side effects during the year they had been followed.
Since clomiphene citrate is not approved by the FDA for use in males, little information exists about the long-term ramifications of carrying it (including the probability of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes medication like clomiphene citrate one of just a few choices for men with low testosterone that 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 since we reliably become fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and then return to research.
Topical treatments help maintain a more uniform level of blood glucose. The first form of topical treatment has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a red area in their skin. That limits its use.
The most widely used testosterone preparation in the United States -- and also the one I begin almost everyone off with -- is a topical gel. The gel comes in tiny tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be consumed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb enough for this to have a favorable effect. [For specifics on various formulations, see table ]
Are there any drawbacks to using dyes? How much time does it take for them to work?
Men who begin using the implants need to come back in to have their testosterone levels measured again to be certain they are absorbing the right quantity. Our goal is the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just a few doses. I usually measure it after two weeks, even though symptoms may not change for a month or two.