A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It might be stated that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, big muscles, and body and facial 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 normal erections. It also 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 energy, erectile dysfunction, diminished 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). Yet it's an underdiagnosed issue, with just about 5 percent of these affected undergoing therapy.
Studies have shown that testosterone-replacement therapy may offer a vast selection of advantages for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. Much of the current debate focuses on the long-held belief that testosterone may 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 expertise 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 believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and see thisfind more infoget redirected here diagnosisWhat symptoms and signs of low testosterone prompt that the average man to see a physician?
As a urologist, I tend to see guys since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much 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 probable 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 guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs which 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 together with it either, 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 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 ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are some guys who have low levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one quite agrees on a few. It is not like diabetes, in which if your fasting sugar 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 recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. |
Is total testosterone the ideal point to be measuring? Or should we be measuring something else?
This is just another area of confusion and great debate, 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 total testosterone, or all the testosterone in the human body. However, 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. Even 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 ideal, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis 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 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 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 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 affect identification. Most guidelines nevertheless say it's important to do the test in the morning, but for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.
There are some very interesting findings about diet. For instance, it seems that those that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear.
Exogenous vs. endogenous testosteroneIn this article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based upon the formulation, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects. Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, known as nitric oxide, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all of the guys had heightened levels of testosterone; none reported some side effects during the entire 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 ramifications of taking it (such as the probability of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few choices for men with low testosterone that 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's cheap 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 can also happen as blood testosterone levels peak and return to research.
Topical therapies 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% of people that used the patch developed a red area on their skin. That restricts its use.
The most widely used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it tends to be consumed to great levels in about 80% to 85 percent of men, but leaves a significant number who don't absorb sufficient for it to have a favorable impact. [For specifics on several different formulations, see table below.]
Are there any drawbacks to using dyes? How long does it take for them to get the job done?
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 the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within several doses. I usually measure it after two weeks, even although symptoms may not change for a month or two.