A Harvard expert shares his Ideas on testosterone-replacement Treatment
It might be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start 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 such as reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5 percent of those affected undergoing therapy.
Studies have revealed that testosterone-replacement therapy may offer a vast range of advantages 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 diseases and male reproductive and sexual difficulties. He's developed particular experience 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 experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical man to find a doctor?
As a urologist, I tend to observe men since they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something which would normally be arousing.
The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing 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 medications that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. However 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 surely if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How can you decide whether a man is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two approaches is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. However, no one really agrees on a few. It is similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. |
Is total testosterone the right thing to be measuring? Or should we be measuring something different?
Well, this is 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 physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream is not available to the 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 is readily available to cells. Nearly every laboratory has a blood test to measure free testosterone. Though it's only a small fraction of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the significance 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 Isn't Suggested for men who have
- Prostate or breast cancer
- a nodule on the prostate that may be felt during a DRE
- that a PSA higher than 3 ng/ml without further evaluation
- a hematocrit greater than 50 percent or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract infections
- class III or browse around here IV pop over to this site heart failure.
Do time of day, diet, or other elements influence testosterone levels?
For 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.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in average testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and over, it likely doesn't matter much, as long as they obtain their blood drawn before 6 or 5 p.m.
There are some rather interesting findings about diet. For instance, it appears that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
Within the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based upon the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.
In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, all the guys had heightened levels of testosteronenone reported some side effects during the year they had been followed.
Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of carrying it (including the probability of developing prostate cancer) or if it is more capable of boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.
FormulationsWhat kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we still use since it is inexpensive and since we faithfully become good testosterone levels in nearly everybody. The disadvantage is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to baseline.
Topical treatments help preserve a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area on their skin. That restricts its usage.
The most widely used testosterone preparation from the United States -- and also the one I start almost everyone off with -- is a topical gel. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to good degrees in about 80% to 85 percent of guys, but leaves a significant number who do not consume sufficient for this to have a favorable impact. [For details on several different formulations, see table below.]
Are there any drawbacks to using gels? How long does it take for them to work?
Men who start using the gels have to come back in to have their testosterone levels measured again to make sure they're absorbing the right amount. Our target is the mid to upper range 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 a few doses. I usually measure it after 2 weeks, even although symptoms may not alter for a month or two.