A Harvard Specialist shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with just about 5 percent 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 can 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 difficulties. He has 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 own patients, and why he thinks specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average man to find a physician?
As a urologist, I have a tendency to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something that 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.
Aren't those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications which may lessen sex drive, including the BPH drugs 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 usually go together with it , though certainly if somebody has less sex drive or less attention, it is more of a struggle to have a good erection.
How do you determine if or not a man is a candidate for testosterone-replacement therapy?
There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two methods is far from ideal. Normally men 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 low levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe 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 clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society why not try this out recommendations summarized." For a complete copy of the guidelines, log on to www.endo-society.org. Is total testosterone the ideal thing to be measuring? Or if we are measuring something different? Well, this is another area of confusion and good debate, but I do not think that it's as confusing as it appears to be 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's circulating in the bloodstream isn't available to the cells. The biologically available portion of overall 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 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 daily, diet, or other elements affect testosterone levels? For many years, the recommendation was to get a testosterone value early in the morning since levels begin to drop after 10 or even 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 mature over the course of this day. One reported no change in typical testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably insufficient to influence identification. Most guidelines nevertheless say it's important to do the evaluation in the morning, however for men 40 and over, it probably doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m. There are some very 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 consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear. Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects. 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, all of the men had heightened levels of testosterone; none reported some side effects throughout the entire year they had been followed. Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists regarding the long-term ramifications of carrying it (including the risk of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who want to father children. |
What forms of testosterone-replacement therapy are available? *
The earliest form is the injection, which we use because it's inexpensive and because we reliably get fantastic testosterone levels in almost everybody. The drawback is that a person needs to come in every few weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and return to baseline.
Topical therapies help preserve a more uniform amount of blood glucose. The first form of topical therapy was a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a red area in their skin. That restricts its use.
The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes in miniature tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to great levels in about 80% to 85% of guys, but that leaves a substantial number who don't consume enough for it to have a favorable impact. [For specifics on various formulations, see table ]
Are there any drawbacks to using gels? How long does it require them to get the job done?
Men who start using the implants need to return in to have their own testosterone levels measured again to make certain they're absorbing the right quantity. Our goal is the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, in just several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.