A Harvard expert shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
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 at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also boosts 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 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 working and"gonadism" referring to the testicles). Yet it's an underdiagnosed problem, with only about 5% of those affected receiving treatment.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks 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 diseases and male sexual and reproductive difficulties. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms webpage and view itdescription diagnosisWhat symptoms and signs of low testosterone prompt that the average person to find a doctor?
As a urologist, I tend to observe guys because 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 should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a feeling 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're often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs that may reduce libido, including the BPH medication 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's 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 just two ways that 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. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is above 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 shouldn't receive testosterone therapy. |
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 that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the blood is not available to the cells. It is tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization urges 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 attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within the course of this 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 is important to perform the evaluation in the morning, however for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 5 or 6 p.m.
There are some very interesting findings about diet. By way of instance, it appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
Exogenous vs. endogenous testosteroneWithin the following guide, 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, along with other side effects. Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the production 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 year they had been followed. Since clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of taking it (such as the risk of developing prostate cancer) or whether 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 just a few choices for men with low testosterone that want to father children. What forms of testosterone-replacement treatment are available? * The earliest form is an injection, which we use since it is 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. [See"Exogenous vs. endogenous testosterone," above.] Topical treatments help maintain a more uniform amount of blood testosterone. The first kind of topical therapy 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 on their skin. That restricts its use. The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. Based on my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of guys, but leaves a significant number who don't consume enough for it to have a favorable effect. [For specifics on several different formulations, see table below.] Are there any drawbacks to using dyes? How much time does it take for them to work? Men who begin using the gels have to come back in to have their own testosterone levels measured again to be sure they're absorbing the right quantity. Our target is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, in just several doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two. |