A Harvard Specialist shares his Ideas on testosterone-replacement therapy
It might be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone like lower libido and sense of energy, erectile dysfunction, decreased 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" speaking to the testicles). Yet it's an underdiagnosed problem, with just about 5% of those affected undergoing therapy.
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 may 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 diseases and male sexual and reproductive problems. He's developed specific 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 he believes specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average man to find a doctor?
As a urologist, I tend to observe 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 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 climaxes, a smaller quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something which would usually be arousing.
The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, but they are 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 precisely. There are quite a few drugs which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally does not go together 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's more of a struggle to get a fantastic erection.
How do you determine if a person is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone has reduced 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. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some 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 is a reasonable guide. However, no one really agrees on a number. It is not like diabetes, in which if your fasting sugar is above a certain level, they will 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 recommendations for you can look here who should and should not check out here receive testosterone therapy. Watch"Endocrine Society investigate this site recommendations summarized." Is total testosterone the ideal point to be measuring? Or should we be measuring something else? This is another area of confusion and great debate, but I do not think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. However, about half of their testosterone that's circulating in the bloodstream isn't available to cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available part of total testosterone is known as free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Though it's just a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the significance is greater compared to testosterone. This professional organization urges testosterone treatment for men who have
Therapy is not recommended for men who've
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Do time of day, diet, or other factors 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 11 a.m.. But the information behind this 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 the day. One reported no change in average testosterone until after 2 Between 2 and 6 p.m., it went down by 13%, a modest amount, and probably not enough to influence diagnosis. Most guidelines still say it's important to do the evaluation in the morning, however for men 40 and over, it likely doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are a number of rather interesting findings about dietary supplements. For example, it appears that individuals that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to make any clear recommendations.
Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Based upon the formula, treatment can lead to 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, can foster the production of natural testosterone, also known as endogenous testosterone, in men. Within four to six months, all the men had increased levels of testosteronenone reported some side effects during the entire year they had been followed.
Because clomiphene citrate isn't accepted by the FDA for use in men, little information exists regarding 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 adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.
What kinds of testosterone-replacement therapy can be found? *
The oldest form is the injection, which we still use because it is inexpensive and since we reliably become good testosterone levels in almost everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to research. [See"Exogenous vs. endogenous testosterone," above.]
Topical treatments help maintain a more uniform amount of blood glucose. The first form of topical treatment was a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area on their skin. That restricts its usage.
The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off with -- is a topical gel. According to my experience, it tends to be absorbed to great degrees in about 80% to 85% of men, but leaves a significant number who do not absorb sufficient for this to have a positive effect. [For details on several different formulations, see table below.]
Are there any downsides 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 testosterone levels measured again to be certain they're absorbing the right quantity. Our goal is the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just a few doses. I usually measure it after two weeks, even although symptoms may not change for a month or two.