A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it boosts 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% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed issue, with just about 5 percent of these affected undergoing therapy.
Studies have shown that testosterone-replacement therapy may offer a wide range of benefits for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. Much of the current debate focuses on the long-held belief that testosterone may 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's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and why 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 see a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience different symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the symptoms there are, 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 are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they are 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 quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not usually go together with it , 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 determine whether 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 signs and symptoms, and the correlation between those two approaches is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are a number of men 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 for a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. However, no one really 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.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and you can check here should Your Domain Name not receive testosterone index therapy. Is total testosterone the ideal point to be measuring? Or should we be measuring something different? This is just another area of confusion and great debate, but I do not think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the human body. But about half of their testosterone that is circulating in the bloodstream is not readily available to cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available portion of overall testosterone is called free testosterone, and it's readily available to cells. Even though it's only a little portion of this total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the correlation is greater compared to testosterone.
Do time of day, diet, or other factors affect testosterone levels? For years, the recommendation was to get a testosterone value early in the morning since levels begin to fall 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 this day. One reported no change in typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to perform the evaluation in the morning, however for men 40 and above, it probably doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m. There are some rather interesting findings about dietary supplements. For example, it appears that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been studied thoroughly enough to make any clear recommendations.
What forms of testosterone-replacement treatment are available? * The earliest form is an injection, which we use because 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 find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to research. [See"Exogenous vs. endogenous testosterone," above.] 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 quite high rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a reddish area in their skin. That limits its usage. The most commonly used testosterone preparation from the United States -- and the one I begin almost everyone off with -- is a topical gel. The gel comes in miniature tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be consumed to good levels in about 80% to 85 percent of men, but that leaves a significant number who don't absorb sufficient for this to have a positive impact. [For details on various formulations, see table ] Are there any drawbacks to using dyes? How long does it take for them to get the job done? Men who begin using the gels have to come back in to have their own testosterone levels measured again to make sure they are absorbing the proper amount. Our target is that the mid to upper assortment 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 a few doses. I normally measure it after two weeks, though symptoms may not change for a month or two. |