A Harvard expert shares his thoughts on testosterone-replacement therapy
It could be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by approximately 1% per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone such as lower libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5% of those affected undergoing therapy.
Various studies have shown that testosterone-replacement therapy can offer a wide selection of benefits for men with hypogonadism, such as 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 may 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 sexual and reproductive problems. He's developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and why he believes experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.
Symptoms and her latest blogdiscover this info here diagnosisWhat signs and symptoms of low testosterone prompt that the average person to find a doctor?
As a urologist, I have a tendency to see men since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.
The more of these symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to discount 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 guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount 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 together with it either, 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 determine if or not a person is a candidate for testosterone-replacement treatment?
There are just two ways that 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 ideal. Normally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But 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* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. However, no one quite agrees on a number. It's not like diabetes, where 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 clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations summarized." |
Is total testosterone the right thing to be measuring? Or should we be measuring something else?
Well, this is another area of confusion and good 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 total testosterone, or all of the testosterone in the human body. However, about half of their testosterone that is circulating in the blood isn't readily available to cells.
The available portion 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 overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the significance is greater compared to total testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone therapy for men who have both Therapy is not recommended for men who have
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Do time of day, diet, or other factors influence testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning because levels start to fall after 10 or even 11 a.m.. But the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of this day. One reported no change in typical 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 do 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 6 or 5 p.m.
There are a number of very interesting findings about dietary supplements. By way of example, it appears that those who 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 adrenal gland -- testosterone that is produced outside the body. Depending upon the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.
Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the creation of natural testosterone, known as endogenous testosterone, in men. Within four to six months, all of the guys had heightened levels of testosteronenone reported some side effects during the entire year they were followed.
Since clomiphene citrate is not approved by the FDA for use in males, little information exists about the long-term ramifications of taking it (including the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enhances -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.
What forms of testosterone-replacement treatment are available? *
The oldest form is the injection, which we use since it is inexpensive and because we faithfully get good testosterone levels in nearly everybody. The drawback is that a person needs to come in every few weeks to find a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to research. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical treatment was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area in their skin. That limits its use.
The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. The gel comes from miniature tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be consumed to great 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 specifics on various 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 quantity. Our goal is that the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, though symptoms may not change for a month or two.