A Harvard expert shares his Ideas on testosterone-replacement Treatment
It might be stated that testosterone is the thing that makes men, men. 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 creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by about 1% per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start 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). Yet it is an underdiagnosed issue, with only about 5 percent of those affected undergoing therapy.
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 particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and why he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average man to find a doctor?
As a urologist, I have a tendency to see men since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men may 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 manhood 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 discount these"soft symptoms" as a normal part of aging, but they're 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 exactly. There are quite a few medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less attention, it is more of a challenge to get a good erection.
How can you decide if a man is a candidate for testosterone-replacement therapy?
There are just two ways that 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 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 entire testosterone level of less than 300 ng/dl, and I think 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 over 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 recommends clinical practice guidelines with recommendations for who should and should not receive pop over to this site testosterone treatment. this page For a complete copy of the guidelines, log on to www.endo-society.org. |
Is total testosterone the right point to be measuring? Or if we are measuring something different?
This is just another area of confusion and good discussion, but I do not think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the human body. However, about half of their testosterone that is circulating in the blood isn't readily available to the cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of overall testosterone is known as free testosterone, and it's readily available to the cells. Even though it's only a small portion of the overall, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the correlation is greater than with total testosterone.
Endocrine Society recommendations summarizedThis professional organization recommends testosterone treatment for men who have
Therapy Isn't recommended for men who have
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Do time of day, diet, or other factors influence testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning because levels begin to fall after 10 or 11 a.m.. However, the information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature within the course of the day. One reported no change in typical testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably insufficient to influence identification. Most guidelines nevertheless say it's important to perform the test in the morning, but for men 40 and over, it probably does not matter much, provided that they obtain their blood drawn before 5 or 6 p.m.
There are some rather interesting findings about diet. By way of example, it appears that individuals that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been studied thoroughly enough to create any recommendations that are clear.
Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending upon the formula, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.
Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the production of natural testosterone, also termed nitric oxide, in men. In 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 men had increased levels of testosterone; none reported some side effects throughout the year they had been followed.
Since clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- 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 forms of testosterone-replacement treatment can be found? *
The oldest form is an injection, which we still use since it is inexpensive and because we faithfully become good testosterone levels in nearly everybody. The disadvantage is that a person should come in every few weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to research.
Topical treatments help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a very high rate of skin irritation. In 1 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. 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 consumed to great degrees in about 80% to 85% of men, but that leaves a substantial number who do not consume sufficient for this to have a favorable impact. [For details on several different 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 testosterone levels measured again to make sure they're absorbing the right amount. Our target is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, in just several doses. I normally measure it after 2 weeks, even although symptoms may not alter for a month or two.