A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It could be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a 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 referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring 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 percent of these affected undergoing therapy.
Various studies have shown that testosterone-replacement therapy may offer a vast selection of advantages for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face.
He's developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and why he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical person to see a doctor?
As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy 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 orgasms, a lesser amount of fluid out of 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 you will find, the more likely it is that a man has low testosterone. Many physicians often dismiss those"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 are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of 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 usually 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 fantastic erection.
How do you decide whether or not a man is a candidate for testosterone-replacement treatment?
There are 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 these two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys 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 to be a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really agrees on a number. 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 apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and you could look here shouldn't receive testosterone treatment. For a original site complete copy of these instructions, log on to home www.endo-society.org. |
Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?
This is another area of confusion and great discussion, but I do not think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. But about half of their testosterone that is circulating in the blood is not available to the cells. It is closely bound to a carrier molecule called 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. Though it's only a small fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone therapy for men who have both
Therapy Isn't Suggested for men who have
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Do time of day, diet, or other factors affect testosterone levels?
For many 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 attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within the course of this day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to perform the evaluation in the morning, however for men 40 and above, it probably doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are some 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 clear recommendations.
Exogenous vs. endogenous testosteroneIn this article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based upon the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects. Preliminary studies have 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 known as nitric oxide, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, each one the guys had increased levels of testosterone; none reported any side effects throughout the entire year they were followed. Since clomiphene citrate isn't approved by the FDA for use in males, little information exists regarding the long-term effects of carrying it (such as the probability of developing prostate cancer) or if it is more capable of boosting testosterone compared to 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 who 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 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 happen as blood testosterone levels peak and return to research. Topical therapies help preserve a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area in their skin. That limits its usage. The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes in tiny tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be absorbed to great levels in about 80% to 85 percent of men, but leaves a substantial number who do not absorb sufficient for this to have a positive effect. [For details on various formulations, see table below.] Are there any downsides to using gels? How much time 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 be sure they're absorbing the proper amount. Our target is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, in just a few doses. I usually measure it after 2 weeks, though symptoms may not alter for a month or two. |