A Harvard Specialist shares his Ideas on testosterone-replacement therapy
It might be said that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" that makes testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1% a year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low functioning 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 is an underdiagnosed issue, with only about 5% of these affected receiving treatment.
Various studies have shown that testosterone-replacement therapy may provide a vast selection of benefits 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 can stimulate prostate cancer.
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 utilizes his own patients, and he thinks experts should reconsider the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average man to find a physician?
As a urologist, I have a tendency to observe men since they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, like more trouble achieving an orgasm, less-intense orgasms, a smaller quantity 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 probable it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that guys have when they're 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 may also reduce the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity usually doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though surely if somebody has less sex drive or less attention, it is more of a struggle to get a good erection.
How can you decide if a man is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between these two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. However, no one quite agrees on a number. It's not like diabetes, where if your fasting glucose is over a certain level, they'll 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 browse around this site who should and shouldn't receive testosterone treatment. For a complete copy of these instructions, log on to www.endo-society.org. Is complete testosterone the ideal thing to be measuring? Or if we are measuring something different? Well, this is just another area of confusion and good debate, but I don't think it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream is not available to the cells. The biologically available part of total testosterone is called free testosterone, and it's readily available to cells. Even though it's only a small portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater compared to total testosterone. This professional organization urges testosterone treatment for men who have
Therapy Isn't recommended for men who've
|
Do time daily, diet, or other factors influence testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning since levels start to fall after 10 or even 11 a.m.. But the information behind that recommendation were drawn from healthy young men. Two recent studies demonstrated 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 p.m. Between 2 and 6 p.m., it went down by 13%, a modest amount, and probably not enough to affect identification. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but 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 some very interesting findings about dietary supplements. By way of instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been studied thoroughly enough to create any clear recommendations.
Within the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based on the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.
Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the production of natural testosterone, known as endogenous testosterone, in men. Within four to six months, each one the guys had heightened levels of testosteronenone reported some side effects during the entire year they had been followed.
Since clomiphene citrate is not approved by the FDA for use in males, little information exists about the long-term effects of carrying it (including 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 enriches -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.
FormulationsWhat forms of testosterone-replacement treatment can be found? *
The earliest form is an injection, which we use because it is inexpensive and because we faithfully get fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and then return to baseline.
Topical therapies help maintain a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a red area in their skin. That limits its use.
The most widely used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes in tiny tubes or within 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 consumed to good levels in about 80% to 85% of guys, but leaves a significant number who don't consume sufficient for it to have a positive effect. [For details on various formulations, see table ]
Are there any drawbacks to using dyes? How long 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're absorbing the right quantity. Our goal is that the mid to upper assortment of normal, which usually means around 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, even although symptoms may not change for a month or two.