A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It might be said that testosterone is what 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 , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by about 1% per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed issue, with just about 5% 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.
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 problems. He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his own patients, and he thinks experts should reconsider the potential connection 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 have a tendency to see men because they have sexual complaints. The main hallmark of low 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 other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount 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 the symptoms there are, 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 same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally does not go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if a person has less sex drive or less attention, it is more of a struggle to get a good erection.
How do you determine if or not a person is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that is a sensible guide. But no one quite agrees on a number. It's not like diabetes, where if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. For a complete copy of go to this site the guidelines, more information log on to www.endo-society.org. |
Is total testosterone the right point to be measuring? Or if we are measuring something different?
This is just another area of confusion and great discussion, but I don't think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the human body. But about half of their testosterone that is circulating in the blood is not available to the cells.
The available part of total testosterone is known as free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's only a little fraction of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the significance is greater compared to total testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone therapy for men who have Therapy Isn't Suggested for men who have
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Do time daily, diet, or other factors affect testosterone levels?
For many years, the recommendation has been to get a testosterone value early in the morning since levels begin to drop after 10 or 11 a.m.. However, the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of the day. One reported no change in average testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a small amount, and probably not enough to affect diagnosis. Most guidelines nevertheless say it's important to perform the test in the morning, however for men 40 and above, it likely doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about dietary supplements. For instance, it appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been researched thoroughly enough to make any recommendations that are clear.
Exogenous vs. endogenous testosteroneWithin this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Depending upon the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced 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 three or more months. Within four to six weeks, each one the guys had heightened levels of testosteronenone reported some side effects during the year they had been followed. Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the risk of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes drugs such as clomiphene citrate one of only a few options for men with low testosterone that wish to father children. |
What kinds of testosterone-replacement treatment are available? *
The oldest form is the injection, which we use since it is cheap and because we reliably get fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to research.
Topical treatments help maintain a more uniform level of blood testosterone. The first kind of topical treatment has been a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a red area on their skin. That restricts its usage.
The most widely used testosterone preparation from the United States -- and also the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. According to my experience, it has a tendency to be consumed to great degrees in about 80% to 85 percent of guys, but leaves a significant number who do not consume sufficient for this to have a favorable impact. [For details on several different formulations, see table ]
Are there any downsides to using dyes? How much time does it require them to get the job done?
Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper 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 the blood actually goes up quite quickly, within a few doses. I normally measure it after 2 weeks, even although symptoms may not alter for a month or two.