A Harvard expert shares his thoughts on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It could be stated that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, big 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 contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" that makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by about 1% per year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like lower sex drive and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with just about 5% of those 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 diseases and male sexual and reproductive difficulties. He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and why he thinks experts should reconsider the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical man to find a physician?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a lesser quantity of fluid from ejaculation, and a sense of numbness in the manhood 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 often 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 lessen sex drive, 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 decrease in orgasm intensity usually doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though certainly if a person has less sex drive or less attention, it is more of a struggle to get a fantastic erection.
How do you decide whether or not a man is a candidate for testosterone-replacement therapy?
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. 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 amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. But no one really agrees on a few. It's similar to 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 clear.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should Clicking Here and should not receive testosterone therapy. For visit site a complete copy of the this content instructions, log on to www.endo-society.org. |
Is complete testosterone the ideal point to be measuring? Or should we be measuring something different?
This is another area of confusion and good debate, but I don't think that it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. However, about half of their testosterone that's circulating in the blood is not readily available to cells.
The biologically available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Nearly every lab has a blood test to measure free testosterone. Though it's just a small portion of this overall, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the correlation is greater than with total testosterone.
Endocrine Society recommendations summarizedThis professional organization urges testosterone treatment for men who have both Therapy is not recommended for men who have
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Do time of day, diet, or other elements affect testosterone levels?
For years, the recommendation has been to get a testosterone value early in the morning since levels begin to drop after 10 or 11 a.m.. However, the data behind that recommendation were drawn from 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 typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, 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 over, it likely does not matter much, provided that they get their blood drawn before 5 or 6 p.m.
There are some very 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 eat more protein. But diet hasn't been studied thoroughly enough to make any clear recommendations.
Within this article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending on the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.
Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, also termed endogenous testosterone, in men. Within four to six weeks, each one the guys had heightened levels of testosterone; none reported some side effects throughout the entire year they were followed.
Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the risk of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. That makes medication like clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.
FormulationsWhat kinds of testosterone-replacement therapy are available? *
The earliest form is the injection, which we use since it's cheap and because we faithfully get 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 occur as blood testosterone levels peak and return to research. [See"Exogenous vs. endogenous testosterone," above.]
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 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 -- is a topical gel. According to my experience, it has a tendency to be absorbed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who don't absorb sufficient for it to have a positive impact. [For specifics on various formulations, see table ]
Are there any downsides to using dyes? How long does it take for them to get the job done?
Men who start using the implants need to come back in to have their 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 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 normally measure it after two weeks, although symptoms may not alter for a month or two.