A Harvard expert shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what 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 fosters the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which produces testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1 percent a year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like lower libido and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with just about 5 percent of those affected receiving treatment.
Various studies have revealed that testosterone-replacement therapy may offer a wide selection of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 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 difficulties. He has developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average man to see a doctor?
As a urologist, I tend to see men because 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 must possess his testosterone level checked. Men can experience different symptoms, like 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 probable it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications which may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no question. But a reduction in orgasm intensity usually doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it , though certainly if somebody has less sex drive or less attention, it is more of a struggle to get a good erection.
How do you decide if a man is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two approaches 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* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. But no one really agrees on a few. It's 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 is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. For a complete copy of these instructions, log on to www.endo-society.org. |
Is total testosterone the ideal thing to be measuring? Or if we are measuring something different?
Well, this is just another area of confusion and great discussion, 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 is circulating in the bloodstream is not readily available to the cells.
The biologically available portion of total testosterone is called free testosterone, and it is readily available to the cells. Nearly every lab has a blood test to measure free testosterone. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the correlation is greater compared to total testosterone.
This professional organization urges testosterone therapy for men who have both
- Reduced levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not Suggested for men who have
- Breast or prostate cancer
- a nodule on the prostate that may be felt during a DRE
- a PSA higher than 3 ng/ml without further analysis
- that a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract infections
- class III or IV website here heart failure.
Do time daily, diet, or other factors influence testosterone levels?
For many 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 the 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 affect diagnosis. Most guidelines still say it is important to perform the evaluation in the morning, but for men 40 and above, it likely does not 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 diet. By way of example, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
Exogenous vs. endogenous testosterone
Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Based upon the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects.
Within four to six months, each one the guys had increased levels of testosteronenone 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 risk of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes medication such as clomiphene citrate one of just a few options for men with low testosterone that wish to father children.
What forms of testosterone-replacement therapy are available? *
The oldest form is the injection, which we use because it's inexpensive and since we reliably get good testosterone levels in nearly everybody. The drawback is that a person should come in every few weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area in their skin. That restricts its usage.
The most widely used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. According to my experience, it has a tendency to be absorbed to good degrees 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 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 implants need to return in to have their testosterone levels measured again to be certain they're absorbing the proper amount. Our target is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, within several doses. I usually measure it after 2 weeks, although symptoms may not alter for a month or two.