A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
It could be stated that testosterone is what makes guys, men. 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 produces testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1 percent a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like reduced 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 United States. Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.
Studies have shown that testosterone-replacement therapy may provide a vast range 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.
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 problems. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and why he thinks specialists should rethink the possible link between testosterone-replacement therapy and prostate cancer.
Symptoms additional hints and diagnosisWhat signs and symptoms of low testosterone prompt that the typical person to see a doctor?
As a urologist, I tend to see men since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis 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're often treatable and reversible by decreasing testosterone levels.
Are not those the very 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 reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if somebody has less sex drive or less interest, it is more of a struggle to have a fantastic erection.
How do you determine if or not a person 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 some guys who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, 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 few. It is 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 isn't quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. |
Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?
Well, this is just another area of confusion and good debate, but I do not think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of the testosterone that's circulating in the blood is not readily available to the cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of total testosterone is known as free testosterone, and it is readily available to the cells. Though it's just a small portion of the overall, the free testosterone level is a pretty good indicator of low testosterone. It is not perfect, but the correlation is greater compared to total testosterone.
Endocrine Society recommendations summarizedThis professional organization urges testosterone therapy for men who have Therapy Isn't Suggested for men who have
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Do time daily, diet, or other elements affect testosterone levels?
For many years, the recommendation has been to get 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 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 till after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a small sum, and probably not enough to affect identification. Most guidelines still say it is important to do the evaluation in the morning, however for men 40 and over, it probably does not matter much, provided that they get their blood drawn before 5 or 6 p.m.
There are a number of rather interesting findings about diet. By way of instance, it appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been studied thoroughly enough to create any recommendations that are clear.
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Depending on the formula, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.
Preliminary research has shown 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 weeks, each one of the men had heightened levels of testosterone; none reported any side effects during the year they were followed.
Because clomiphene citrate is not approved by the FDA for use in men, little information exists regarding the long-term ramifications of carrying it (such as the probability 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 possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.
What kinds of testosterone-replacement treatment are available? *
The oldest form is an injection, which we still use because it's cheap and since we faithfully become fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline. [See"Exogenous vs. endogenous testosterone," above.]
Topical therapies help maintain a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a quite high rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a reddish area on their skin. That limits its usage.
The most widely used testosterone preparation from the United States -- and the one I start almost everyone off with -- 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 has a tendency to be absorbed to good levels in about 80% to 85 percent of men, but that leaves a substantial number who do not absorb enough for this to have a positive effect. [For details on various formulations, see table below.]
Are there any downsides to using gels? How long does it require them to work?
Men who begin using the gels have to come back in to have their testosterone levels measured again to make certain they're absorbing the proper amount. Our target is that the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, within several doses. I usually measure it after 2 weeks, even though symptoms may not alter for a month or two.