A Harvard expert shares his thoughts on testosterone-replacement Treatment
It could be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large 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 fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" which produces testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent per year, starting in the 40s. As guys get in 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, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low working and"gonadism" speaking 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 problem, with only about 5% of those affected receiving treatment.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks 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 reproductive and sexual problems. He's developed specific expertise 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 he believes specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and pop over hereContinuedread what he said diagnosisWhat symptoms and signs of low testosterone prompt the average man to see a physician?
As a urologist, I have a tendency to observe men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.
The more of these symptoms there are, the more probable it is that a man has low testosterone. Many physicians tend to 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 same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications that 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 does not go together with treatment 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 have a good erection.
How can you decide whether or not a man 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 is by characteristic signs and symptoms, and the correlation between those two methods is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.
Looking 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's a reasonable guide. But no one really agrees on a number. It is not like diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. |
Is complete testosterone the ideal thing to be measuring? Or if we are measuring something else?
Well, this is just another area of confusion and great debate, but I do not think that 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 of the testosterone in the human body. But about half of the testosterone that is circulating in the blood is not available to cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of overall testosterone is known as free testosterone, and it is readily available to cells. Though it's just a small fraction of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the significance is greater than with total 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 factors affect testosterone levels?
For years, the recommendation has been to get a testosterone value early in the morning because levels start to drop after 10 or 11 a.m.. But the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within 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 modest amount, and probably not enough to influence diagnosis. Most guidelines still say it's important to do the test in the morning, but for men 40 and above, it probably doesn't matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about dietary supplements. By way of instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.
Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Depending upon the formula, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.
In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, each one of the men had increased levels of testosteronenone reported some side effects during the entire year they had been followed.
Because clomiphene citrate isn't accepted by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, 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.
FormulationsWhat kinds of testosterone-replacement therapy can be found? *
The oldest form is the injection, which we still use since it is inexpensive and since we reliably become good testosterone levels in almost everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and return to research.
Topical therapies help preserve a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a reddish area on their skin. That restricts its use.
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 men, but leaves a significant number who do not absorb sufficient for it to have a favorable effect. [For details on various formulations, see table ]
Are there any downsides to using gels? How much time does it take for them to get the job done?
Men who start using the implants need to come back in to have their own testosterone levels measured again to make certain they're absorbing the proper amount. Our goal is that the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just a few doses. I normally measure it after 2 weeks, though symptoms may not alter for a month or two.