A Harvard expert shares his thoughts on testosterone-replacement therapy
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, big muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" which produces testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting 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 reduced libido and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of these affected receiving treatment.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and why he believes experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average man to find a doctor?
As a urologist, I have a tendency to observe men since they have sexual complaints. The primary hallmark of low testosterone is reduced 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 different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser quantity of fluid from 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 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, but they're often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of drugs which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity normally does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go along with it , though certainly if somebody has less sex drive or less attention, it is more of a challenge to get a good erection.
How can you decide if a man is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are a number of guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, 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 really agrees on a few. It's not like diabetes, where if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. For a complete why not try these out copy of these instructions, log on to click this site www.endo-society.org. |
Is total testosterone the right thing to be measuring? Or should we be measuring something else?
This is just another area of confusion and good discussion, but I don't think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream is not available to the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of overall testosterone is called free testosterone, and it's readily available to the cells. Even though it's only a small portion of this overall, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater compared to total testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone therapy for men who have both Therapy is not Suggested for men who've
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