A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is the thing that makes guys, men. 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" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning 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 energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with only about 5% of these affected undergoing therapy.
Various studies have revealed that testosterone-replacement therapy can offer a wide range of benefits for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers 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 ailments and male sexual and reproductive problems. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own patients, and why he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical person to find a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a lesser amount of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something which would normally 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 which 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 surely if somebody has less sex drive or less attention, it is more of a challenge to have a good erection.
How can you determine if a person is a candidate for testosterone-replacement therapy?
There are just two ways we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. However, there are some guys who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one quite agrees on a few. It's not like diabetes, in which if your fasting glucose is above 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 should not receive testosterone this contact form therapy. Watch"Endocrine Society recommendations summarized." For a a knockout post complete copy of these guidelines, log his response on to www.endo-society.org. |
Is total testosterone the ideal point 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 is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about overall 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 is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of total testosterone is called free testosterone, and it is readily available to cells. Though it's just a little 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 Isn't Suggested 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 begin to fall after 10 or even 11 a.m.. However, the information behind this 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 average testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient 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, provided that they obtain their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about diet. For example, it appears that individuals 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 the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects. Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the production of natural testosterone, termed endogenous testosterone, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, all the guys had heightened levels of testosterone; none reported some side effects during the 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 effects of taking it (such as the risk of developing prostate cancer) or if it's more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes medication such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children. What kinds of testosterone-replacement therapy can be found? * The oldest form is the injection, which we still use since it's 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 occur as blood glucose levels peak and then return to research. 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 red 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. Based on my experience, it has a tendency to be consumed to good degrees in about 80% to 85 percent of men, but leaves a significant number who do not absorb sufficient for this to have a positive impact. [For details on various formulations, see table below.] Are there any downsides to using gels? How long does it require them to work? Men who start using the implants need to return in to have their testosterone levels measured again to make certain they're absorbing the right quantity. Our goal is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I usually measure it after two weeks, even although symptoms may not change for a month or two. |