A Harvard expert shares his thoughts on testosterone-replacement Treatment
It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the development of the genitals , 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 testicular"machinery" that makes testosterone gradually becomes less effective, 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 symptoms and signs of low testosterone like reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.
Studies have shown that testosterone-replacement therapy may offer a wide range of benefits for men with hypogonadism, including improved 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 diseases and male reproductive and sexual problems. He's developed particular 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 why he thinks experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical man to see a doctor?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would usually 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, 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 precisely. There are quite a few drugs that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go along with it , though certainly if a person has less sex drive or less interest, it is 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 somebody has reduced testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men 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 think that is a sensible guide. But no one quite agrees on a few. It's not like diabetes, in which if your fasting glucose is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines Click Here with recommendations for who should click here to read and shouldn't receive testosterone therapy. find more information Is complete testosterone the ideal thing 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 is apparently from the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the body. But about half of the testosterone that's circulating in the blood isn't available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Though it's just a small fraction of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the correlation is greater compared to testosterone.
Do time of day, diet, or other factors affect testosterone levels? For years, the recommendation has been to get a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines still say it's important to do the test in the morning, but for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m. There are a number of rather interesting findings about dietary supplements. By way of instance, it seems that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
What kinds of testosterone-replacement treatment are available? * The earliest form is an injection, which we use since it's cheap and since we reliably become fantastic testosterone levels in nearly everybody. The drawback is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect can 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 amount of blood testosterone. 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 in their skin. That limits its usage. The most commonly used testosterone preparation from the United States -- and the one I begin almost everyone off with -- is a topical gel. Based on my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of guys, but that leaves a significant number who don't consume sufficient for it to have a favorable impact. [For specifics on several different formulations, see table below.] Are there any downsides to using gels? How much time does it require them to work? Men who begin using the gels have to return in to have their testosterone levels measured again to make certain they're absorbing the right quantity. Our target is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, in just several doses. I usually measure it after two weeks, even although symptoms may not change for a month or two. |