A Harvard Specialist shares his Ideas on testosterone-replacement therapy
It might be said that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels start to fall, by approximately 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone like lower sex drive and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with just about 5 percent of these affected undergoing therapy.
Various studies have revealed that testosterone-replacement therapy can 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 reproductive and sexual problems. He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average man to find a physician?
As a urologist, I tend to observe guys because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense climaxes, a lesser quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications that may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount 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 somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How do you decide if a man is a candidate for testosterone-replacement therapy?
There are 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 these two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. But there are some guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible 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'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations summarized." |
Is total testosterone the ideal point to be measuring? Or should we be measuring something else?
This is just another area of confusion and great 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 heard about total testosterone, or all the testosterone in the human body. However, about half of the testosterone that is circulating in the blood isn't available to cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of total testosterone is called free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's just a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater than with total testosterone.
This professional organization recommends testosterone therapy for men who have both
- Low levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not Suggested for men who've
- Prostate or breast cancer
- a nodule on the prostate that can be felt during a DRE
- a PSA greater than 3 ng/ml without additional analysis
- a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III read more or IV go nowcheck my source heart failure.
Do time daily, diet, or other elements influence testosterone levels?
For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to drop after 10 or 11 a.m.. But the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature within the course of this day. One reported no change in typical testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably not enough to influence diagnosis. Most guidelines still say it is important to perform the test in the morning, however for men 40 and over, it likely does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.
There are some very interesting findings about diet. By way of instance, it appears that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to make any clear recommendations.
Within this article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending on the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.
Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, known as nitric oxide, in men. Within four to six months, all of the guys had increased levels of testosterone; none reported some side effects during the year they were followed.
Since clomiphene citrate isn't approved by the FDA for use in males, little information exists about the long-term effects of carrying it (including the probability of developing prostate cancer) or whether it's more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children.
What kinds of testosterone-replacement therapy can be found? *
The oldest form is the injection, which we still use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The disadvantage is that a person needs to come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical therapies help preserve a more uniform level of blood glucose. The first form of topical treatment has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a reddish area in their skin. That limits its usage.
The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. Based on my experience, it has a tendency to be consumed to good degrees in about 80% to 85% of guys, but leaves a significant number who don't consume enough for it to have a favorable effect. [For specifics on several different formulations, see table below.]
Are there any drawbacks to using dyes? How much time does it take for them to work?
Men who begin using the implants need to come back in to have their own testosterone levels measured again to be certain they're absorbing the proper quantity. Our target is the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, in just several doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two.