Examining No-Hassle hrt Products

A Harvard expert shares his Ideas on testosterone-replacement therapy

An interview with Abraham Morgentaler, M.D.

It could be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating 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 production of red blood cells, boosts mood, and aids cognition.

As time passes, the "machinery" that makes testosterone slowly becomes less powerful, and testosterone levels begin to fall, by about 1% a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of those affected undergoing therapy.

Various studies have shown that testosterone-replacement therapy can offer a vast range of advantages for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production.

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 uses with his patients, and why he believes experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt the average person to find a physician?

As a urologist, I tend to observe men since they have sexual complaints. The main hallmark of reduced testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, like 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 that 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 tend to discount those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.

Are not 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 drugs which may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. But a decrease in orgasm intensity usually doesn't go together with therapy for BPH. Erectile dysfunction does not usually go together with it , though certainly if a person has less sex drive or less interest, it is more of a struggle to have a good erection.

How can you determine whether or not a person is a candidate for testosterone-replacement treatment?

There are just two ways that we determine whether someone has reduced testosterone. One is a blood test and the other one 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 guys with highest testosterone possess the least. However, there are some men who have reduced levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a number. It's similar to diabetes, in which if your fasting glucose 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 recommends clinical practice guidelines with recommendations for who should and go to my site should not receive testosterone therapy. Watch"Endocrine browse this site Society recommendations summarized."

Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?

This is another area of confusion and great debate, but I don't think that it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. But about half of their testosterone that is circulating in the blood isn't readily available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of overall testosterone is known as free testosterone, and it's readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's only a little portion of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the significance is greater compared to total testosterone.

This professional organization recommends testosterone therapy for men who have

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

Therapy Isn't Suggested for men who have

Prostate or breast cancer
a nodule on the prostate that may be felt during a DRE
a PSA greater than 3 ng/ml without additional analysis
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 daily, diet, or other elements affect testosterone levels?

For years, the recommendation was to get a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. But 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 over the course of this day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a small sum, and probably insufficient to influence diagnosis. Most guidelines still say it is important to perform the evaluation in the morning, however for men 40 and over, it probably does not matter much, as long as they get their blood drawn before 5 or 6 p.m.

There are a number of very interesting findings about dietary supplements. By way of instance, it seems that those that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been studied thoroughly enough to make any recommendations that are clear.

Exogenous vs. endogenous testosterone

In the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Based on the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects.

Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, termed nitric oxide, in men. 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 guys had increased levels of testosterone; none reported any 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 effects of taking it (including the probability of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone who want to father children.

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

The earliest form is an injection, which we still use because it is inexpensive and since we faithfully get good testosterone levels in nearly everybody. The drawback is that a man should come in every couple of weeks to find a shot. A roller-coaster effect may also happen as blood testosterone levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical therapies help maintain a more uniform level of blood testosterone. The first form of topical therapy was 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 restricts its usage.

The most widely 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 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 absorbed to good degrees in about 80% to 85% of men, but that leaves a substantial number who don't absorb enough for this to have a positive impact. [For details on various formulations, see table ]

Are there any downsides to using gels? How long does it require them to get the job done?

Men who begin using the implants need to return in to have their own testosterone levels measured again to make sure they're absorbing the right amount. Our goal is the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within a few doses. I normally measure it after 2 weeks, even although symptoms may not change for a month or two.

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