A Harvard Specialist shares his thoughts on testosterone-replacement therapy
It could 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, distinguishing them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also fosters the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by about 1 percent per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone such as lower libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed issue, with only about 5% of these affected receiving treatment.
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 ailments and male sexual and reproductive problems. He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and why he believes experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average person to see a doctor?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much 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 these symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications which may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How can you determine whether a person is a candidate for testosterone-replacement treatment?
There are two ways we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from ideal. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are some men who have low levels of testosterone in their blood and have no signs.
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. But no one quite agrees on a number. It's not like diabetes, where if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. For a hop over to these guys complete copy of the instructions, log on to why not try these out www.endo-society.org. Is total testosterone the ideal point to be measuring? Or if we are measuring something different? This is just another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. But about half of their testosterone that is circulating in the blood isn't available to the cells. The available part of overall testosterone is known as free testosterone, and it is readily available to cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's only a small portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the correlation is greater than with testosterone.
Do time of day, diet, or other elements influence testosterone levels? For years, the recommendation has been to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. But the data behind this recommendation were drawn from 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 average testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably not enough to influence identification. Most guidelines still say it is important to perform the test in the morning, however for men 40 and over, it probably does not 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 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. Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- 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, along with other side effects. Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the creation of natural testosterone, termed nitric oxide, 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 weeks, each one of the men had increased levels of testosterone; none reported some side effects during the year they had been followed. Because clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (including the probability of developing prostate cancer) or whether it is more capable of boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. That makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone who wish to father children. |
What forms of testosterone-replacement treatment are available? *
The oldest form is an injection, which we use since it is cheap and because we reliably get fantastic testosterone levels in almost everybody. The disadvantage is that a man should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to research.
Topical therapies help maintain a more uniform amount of blood glucose. The first kind of topical therapy was a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a red area on their skin. That limits its use.
The most commonly used testosterone preparation in the United States -- and the one I begin almost everyone off -- is a topical gel. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be absorbed to good levels in about 80% to 85% of guys, but leaves a substantial number who do not consume sufficient for this to have a favorable effect. [For specifics on various formulations, see table below.]
Are there any drawbacks to using gels? How long does it take for them to work?
Men who start using the gels have to come back in to have their testosterone levels measured again to make sure they're absorbing the right amount. Our target is 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, within a few doses. I usually measure it after two weeks, though symptoms may not change for a month or two.