A Harvard expert shares his Ideas on testosterone-replacement therapy
It might be said that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing 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 fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as reduced libido and sense of energy, erectile dysfunction, decreased energy, reduced 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" speaking to the testicles). Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.
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 problems. He's developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his patients, and he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms see post and find out this hereLearn More Here 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 main hallmark of low testosterone is low sexual libido or desire, but another can 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 smaller amount of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.
The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that 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. But a decrease in orgasm intensity normally doesn't go along with therapy for BPH. Erectile dysfunction does not usually 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 good erection.
How can you determine if a person is a candidate for testosterone-replacement therapy?
There are just two ways we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. 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* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really agrees on a few. It's similar to diabetes, in which if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not 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?
Well, this is just another area of confusion and good debate, but I don't think it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. However, about half of the testosterone that's circulating in the bloodstream isn't readily available to cells.
The available part of total testosterone is called 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 the total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, 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 receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind this 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 typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines still say it's important to do the test in the morning, however for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are a number of rather interesting findings about dietary supplements. By way of example, it appears that individuals that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
Exogenous vs. endogenous testosteroneIn the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- 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, and 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 known as endogenous testosterone, in men. 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, all the guys had increased 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 (including the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone that want 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 since we faithfully get fantastic 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 treatments help maintain a more uniform amount of blood testosterone. The first form of topical treatment 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 the one I begin almost everyone off -- is a topical gel. The gel comes in tiny tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be absorbed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb enough for this to have a positive effect. [For specifics on various formulations, see table ] Are there any downsides to using gels? How much time does it take for them to get the job done? 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 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 fast, within several doses. I normally measure it after 2 weeks, though symptoms may not alter for a month or two. |