A Harvard expert shares his Ideas on testosterone-replacement therapy
It might be stated that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "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" meaning low functioning 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 issue, with just about 5 percent of these affected receiving treatment.
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'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 own patients, and he believes experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average person to find a doctor?
As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that 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 tend to discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Are not 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 quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though certainly if a person has less sex drive or less interest, it is more of a challenge to have a fantastic erection.
How can you determine whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways 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 these two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some 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 believe that's a sensible guide. But no one quite agrees on a few. It is not like diabetes, in which if your fasting sugar is over a certain level, they will 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 shouldn't explanation receive testosterone treatment. For a complete copy of these instructions, log on Look At This to over here www.endo-society.org. |
Is total testosterone the right point to be measuring? Or if we are measuring something else?
Well, this is just another area of confusion and good debate, but I don't think that it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. However, about half of their testosterone that's circulating in the bloodstream isn't readily available to the cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available portion of total testosterone is called free testosterone, and it is readily available to the cells. Even though it's only a little fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the significance is greater compared to total testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone treatment for men who have Therapy is not recommended for men who have
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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 this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within 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 modest amount, and probably not enough to influence 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 obtain their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about diet. For example, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear.
Exogenous vs. endogenous testosteroneIn this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects. Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the production of natural testosterone, also known as nitric oxide, in men. Within four to six weeks, each one of the men had increased levels of testosteronenone reported some side effects throughout the year they were followed. Since clomiphene citrate is not approved by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (including the probability of developing prostate cancer) or if it is more effective at boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone who wish to father children. What kinds of testosterone-replacement therapy are available? * The earliest form is an injection, which we use since 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 amount of blood testosterone. The first kind of topical therapy has been 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 usage. The most commonly used testosterone preparation from the United States -- and the one I begin almost everyone off with -- is a topical gel. According to my experience, it tends to be consumed to good degrees in about 80% to 85% of men, but leaves a significant number who don't consume sufficient for it to have a favorable effect. [For specifics on several different formulations, see table below.] Are there any downsides to using dyes? How long does it take for them to get the job done? Men who start using the gels have to return in to have their testosterone levels measured again to make certain they're absorbing the right quantity. Our goal is the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within a few doses. I usually measure it after 2 weeks, even though symptoms may not change for a month or two. |