A Harvard expert shares his Ideas on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It could be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it 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 called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed issue, with just about 5% of those affected receiving treatment.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 ailments and male reproductive and sexual 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 why he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average man 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 any man 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 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 reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though certainly if a person has less sex drive or less interest, it is more of a challenge to have a good 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 perfect. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one really agrees on a few. It's similar to 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.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. |
Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?
Well, this is another area of confusion and good debate, but I don't 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's circulating in the blood isn't readily available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Though it's only a small fraction of this overall, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the significance is greater compared to total testosterone.
This professional organization urges testosterone treatment for men who have
- Reduced levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy Isn't Suggested for men who've
- Breast or prostate cancer
- a nodule on the prostate that can be felt during a DRE
- a PSA greater than 3 ng/ml without further evaluation
- a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract infections
- class III dig thislook at this web-site or check over here IV heart failure.
Do time of day, diet, or other elements influence 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 is 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 seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear.
FormulationsExogenous vs. endogenous testosterone
In the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Based upon the formula, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.
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, each one of 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 probability of developing prostate cancer) or whether it's more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone that want to father children.
What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we use since it's cheap and since we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to baseline.
Topical treatments help maintain a more uniform amount of blood testosterone. The first form 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 red area on their skin. That restricts its use.
The most widely used testosterone preparation in the United States -- and the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be consumed to good levels in about 80% to 85 percent of men, but that leaves a significant number who don't absorb sufficient for this to have a positive effect. [For details on various formulations, see table below.]
Are there any downsides to using dyes? How long does it take for them to get the job done?
Men who start using the gels have 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 range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, in just several doses. I usually measure it after two weeks, even though symptoms may not alter for a month or two.