A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
It might be said that testosterone is the thing that 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 , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the production of red blood cells, boosts mood, and aids cognition.
As time passes, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels begin 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 anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed problem, with only about 5 percent 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 diseases and male reproductive and sexual difficulties. He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and why he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical person to find a physician?
As a urologist, I have a tendency to observe men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men may experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser quantity 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 are 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 a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go along with it either, though certainly if a person has less sex drive or less attention, it is more of a challenge to get a good erection.
How can you decide if a man is a candidate for testosterone-replacement therapy?
There are just 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 sensible guide. But no one quite agrees on a few. It is not like diabetes, where if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations visit their website for who should and shouldn't receive testosterone treatment. For a complete copy of these guidelines, log on to www.endo-society.org. |
Is total testosterone the ideal point to be measuring? Or should we be 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 in the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream isn't available to 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's readily available to cells. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the correlation is greater compared to total testosterone.
Endocrine Society recommendations summarizedThis professional organization urges testosterone therapy for men who have Therapy is not Suggested for men who have
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Do time of day, 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 older 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 diagnosis. Most guidelines nevertheless say it's important to do the evaluation in the morning, however for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are some very interesting findings about dietary supplements. By way of example, it appears that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any clear recommendations.
Exogenous vs. endogenous testosteroneIn the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based on the formulation, treatment can cause skin irritation, breast tenderness and enlargement, 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 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 about the long-term effects of taking it (including 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 potentially enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone that wish to father children. |
What forms of testosterone-replacement treatment can be found? *
The earliest form is the injection, which we still use because it's inexpensive and since we faithfully become fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to baseline.
Topical therapies help maintain a more uniform amount of blood glucose. The first form of topical treatment was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a reddish area in their skin. That limits its use.
The most widely used testosterone preparation from the United States -- and 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 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 consumed to good levels in about 80% to 85 percent of men, but that leaves a significant number who do not absorb sufficient for this to have a positive impact. [For details on various formulations, see table ]
Are there any drawbacks to using gels? How much time does it take for them to work?
Men who begin 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 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 a few doses. I normally measure it after two weeks, even though symptoms may not alter for a month or two.