A Harvard expert shares his Ideas on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It might be said 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 growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" which produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent per year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone such as reduced sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5% of these affected receiving treatment.
Studies have revealed that testosterone-replacement therapy may provide a wide selection of advantages for men with hypogonadism, including enhanced 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.
He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and he believes specialists should rethink the possible connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average person to see a physician?
As a urologist, I tend to observe men since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much smaller quantity 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 the symptoms there are, 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 are often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of drugs which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go along with it , though surely if somebody has less sex drive or less attention, it is more of a challenge to get a fantastic erection.
How do you decide whether a man is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess 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* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. However, no one really agrees on a few. It is similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who go to this website should and shouldn't receive testosterone therapy. For a complete copy more tips here of these instructions, log on to www.endo-society.org. Is total testosterone the right thing to be measuring? Or should we be measuring something else? Well, this is another area of confusion and great debate, but I don't think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't readily available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available portion of overall testosterone is known as free testosterone, and it is readily available to cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the significance is greater than with total testosterone. This professional organization urges testosterone therapy for men who have both Therapy Isn't Suggested for men who've
|
Do time daily, diet, or other elements affect testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning because levels start to fall after 10 or 11 a.m.. But 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 mature over the course of the day. One reported no change in typical testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably not enough to affect identification. Most guidelines still say it is important to do the evaluation in the morning, however for men 40 and above, it likely doesn't matter much, provided that they get their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about dietary supplements. For instance, it appears that those that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to make any clear recommendations.
Exogenous vs. endogenous testosteroneIn the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based on the formula, treatment can lead to 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, all the guys had heightened levels of testosteronenone reported some side effects throughout the year they were followed. Because clomiphene citrate is not 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 enriches -- sperm production. This makes drugs like clomiphene citrate one of just a few choices for men with low testosterone who wish to father children. |
What kinds of testosterone-replacement treatment are available? *
The earliest form is the injection, which we still use because it is cheap and because we reliably become fantastic testosterone levels in nearly everybody. The disadvantage is that a person should come in every few weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to research. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a very large 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 limits its use.
The most widely used testosterone preparation from the United States -- and also the one I start almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it has a tendency to be consumed to great levels in about 80% to 85% of men, but that leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For details on various formulations, see table below.]
Are there any drawbacks to using gels? How long does it take for them to work?
Men who start using the gels have to come back in to have their own testosterone levels measured again to be certain they are absorbing the proper quantity. Our target is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, though symptoms may not change for a month or two.