A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
It might be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating 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 produces testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low working and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it's 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.
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 difficulties. He has developed particular 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 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 person to find a doctor?
As a urologist, I tend to observe men because they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, such as 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 the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men 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 surely if somebody has less sex drive or less attention, it's more of a struggle to have a good erection.
How can you determine if a person 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 ideal. 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 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 number. It is not like diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and use this link should not receive testosterone therapy. link For a Read More Here complete copy of the instructions, log on to www.endo-society.org. |
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 overall testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream is not readily available to cells. It's 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 known as free testosterone, and it is readily available to cells. Even though it's only a little fraction of this overall, the free testosterone level is a fairly good indicator of low 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 is not Suggested for men who've
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Do time of day, diet, or other factors influence testosterone levels?
For years, the recommendation was 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 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 amount, and probably not enough to influence diagnosis. Most guidelines still say it is important to perform the evaluation in the morning, but for men 40 and above, it probably doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m.
There are a number of rather interesting findings about dietary supplements. By way of instance, it seems that those 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.
In the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Depending upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.
Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation 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 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 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 enhances -- sperm production. This makes medication like clomiphene citrate one of just a few choices 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 cheap and because 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 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 men who used the patch developed a reddish area on their skin. That restricts its use.
The most widely 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 absorbed to good degrees in about 80% to 85% of guys, but leaves a significant number who don't 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 begin using the gels have to return in to have their own testosterone levels measured again to make sure they are absorbing the proper amount. Our target is that the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within a few doses. I normally measure it after 2 weeks, though symptoms may not change for a month or two.