A Harvard Specialist 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 girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and contributes to normal erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "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 might begin to have symptoms and signs of low testosterone like reduced libido 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's an underdiagnosed problem, with only about 5% of those affected receiving treatment.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms check my referencetry this web-site and description diagnosisWhat signs and symptoms of low testosterone prompt that the typical man to see a physician?
As a urologist, I tend to see men since they have sexual complaints. The main hallmark of reduced testosterone is low 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 climaxes, a smaller quantity 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 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'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 exactly. There are quite a few medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. 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 surely if somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How can you determine if a person 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 perfect. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.
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 think that is a reasonable guide. But no one really agrees on a number. It is similar to diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. |
Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?
This is another area of confusion and great discussion, 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 of the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't available to the cells. It's closely bound to a carrier molecule known as 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 the cells. Almost every lab has a blood test to measure free testosterone. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the correlation is greater than with total testosterone.
This professional organization urges testosterone therapy for men who have both
Therapy is not Suggested for men who've
- Breast or prostate cancer
- a nodule on the prostate which can be felt during a DRE
- a PSA greater than 3 ng/ml without further evaluation
- a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III or IV heart failure.
Do time of day, diet, or other elements affect testosterone levels?
For years, the recommendation has been to receive 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 showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a small sum, and probably insufficient to affect identification. Most guidelines still say it's important to do the evaluation in the morning, however for men 40 and over, it likely 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. 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 has not been researched thoroughly enough to create any clear recommendations.
Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Depending 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 other side effects.
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, each one of the guys had increased levels of testosterone; none reported some side effects during the year they had been followed.
Because clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the risk of developing prostate cancer) or if it's more effective at boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes medication 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 the injection, which we still use since it is inexpensive and because we faithfully 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 quite high rate of skin irritation. In 1 study, as many as 40% of people that 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. There are just two brands: AndroGel and Testim. According to 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 consume sufficient for it to have a favorable effect. [For details on several different formulations, see table below.]
Are there any downsides to using gels? How long does it require them to work?
Men who begin using the implants need to come back in to have their own testosterone levels measured again to make sure they are absorbing the right quantity. Our target is that the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the 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.