A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It might be stated that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" which makes testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1% a year, beginning in the 40s. As guys 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, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low working and"gonadism" referring 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.
He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his patients, and he thinks 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 see a doctor?
As a urologist, I have a tendency to see men because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller quantity 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 these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that guys 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 drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it either, though certainly if a person has less sex drive or less attention, it is more of a struggle to get a fantastic erection.
How do you determine whether or not a man 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 is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are a number of guys 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's a reasonable guide. However, no one really agrees on a few. It's not like diabetes, where if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with click this recommendations for who should and shouldn't receive this post testosterone treatment. Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different? Well, this is another area of confusion and good debate, but I don't think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. However, about half of their testosterone that is circulating in the bloodstream is not available to the cells. The available part of overall testosterone is called free testosterone, and it is readily available to the cells. Almost every laboratory has a blood test to measure free testosterone. Even though it's just a little portion of the overall, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the correlation is greater compared to total testosterone.
Do time of day, diet, or other elements affect testosterone levels? For years, the recommendation has been to get a testosterone value early in the morning because levels start to drop after 10 or even 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 mature over the course of the day. One reported no change in typical testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a small sum, and probably not enough to affect identification. Most guidelines nevertheless say it's important to do the evaluation in the morning, however for men 40 and above, it likely doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m. There are a number of very interesting findings about dietary supplements. By way of example, it seems that individuals who 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 create any recommendations that are clear. Within this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced 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, and additional side effects. Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the creation 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 months, all of the men had increased levels of testosteronenone reported any side effects throughout the entire year they were followed. Because clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term effects of taking it (such as the risk of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone who wish to father children. |
What kinds of testosterone-replacement treatment are available? *
The oldest form is an injection, which we use because it's cheap and because we reliably become fantastic testosterone levels in almost everybody. The drawback is that a person should come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood testosterone levels peak and then return to baseline. [See"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 high rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area on their skin. That limits its use.
The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. The gel comes from tiny tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be consumed to good degrees in about 80% to 85 percent of guys, but leaves a substantial number who don't consume sufficient for it to have a favorable impact. [For specifics on various formulations, see table ]
Are there any drawbacks to using dyes? How much time does it require them to get the job done?
Men who start using the gels have to come back in to have their own testosterone levels measured again to make certain they are absorbing the right quantity. Our target is that the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just several doses. I normally measure it after two weeks, although symptoms may not alter for a month or two.