A Harvard expert shares his Ideas on testosterone-replacement Treatment
It could 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, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed issue, with only about 5% of those affected receiving treatment.
Studies have shown that testosterone-replacement therapy can offer a wide selection of advantages for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face.
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 difficulties. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his patients, and he believes specialists should rethink 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 doctor?
As a urologist, I tend to observe men since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a lesser amount of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally be arousing.
The more of the 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, however, they are often treatable and reversible by normalizing testosterone levels.
Are not 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 that may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go together with it either, though surely if a person has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How do you decide whether a person 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 one is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are a number of guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one really agrees on a number. It's similar to diabetes, where 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 clear.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. |
Is complete testosterone the ideal thing to be measuring? Or if we are measuring something different?
Well, this is another area of confusion and great discussion, but I do not think that it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the human body. But about half of the testosterone that's circulating in the blood isn't readily available to cells. It's tightly 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's readily available to the cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the correlation is greater compared to total testosterone.
Endocrine Society recommendations summarizedThis professional organization urges testosterone treatment for men who have Therapy is not recommended for men who have
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What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we still use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback 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 level of blood glucose. The first form of topical therapy has been a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a red area on their skin. That limits its use.
The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. Based on my experience, it has a tendency to be absorbed to good degrees in about 80% to 85 percent of men, but that leaves a substantial number who do not consume enough for it to have a favorable impact. [For details on various formulations, see table below.]
Are there any drawbacks to using dyes? How long does it take for them to get the job done?
Men who begin using the gels have to come back in to have their testosterone levels measured again to make sure they are absorbing the right amount. 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 really goes up quite fast, in just several doses. I usually measure it after 2 weeks, even although symptoms may not change for a month or two.