A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
It might be said that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the production of red blood cells, boosts mood, and aids cognition.
As time passes, the testicular"machinery" which produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by approximately 1% per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like lower sex drive and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of those affected undergoing therapy.
Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average man to find a physician?
As a urologist, I have a tendency to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may 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 the symptoms there are, the more likely 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.
Are not those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not usually 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 determine 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 one is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are some men who have reduced levels of testosterone in their blood and have no signs.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. However, no one really agrees on a number. It is not like diabetes, in which if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone view treatment. Watch"Endocrine Society recommendations summarized." For a complete copy of the guidelines, log on to www.endo-society.org. Is total testosterone the ideal thing to be measuring? Or should we be measuring something different? Well, this is just another area of confusion and good debate, but I do not think it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. But about half of their testosterone that's circulating in the blood is not available to cells. It is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available portion of total testosterone is known as free testosterone, and it's readily available to cells. Though it's only a little fraction of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater compared to total testosterone. This professional organization recommends testosterone treatment for men who have both
Therapy is not recommended for men who've
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Do time daily, diet, or other factors affect testosterone levels?
For many years, the recommendation has been to get a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of the day. One reported no change in typical testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it is important to do the evaluation in the morning, however for men 40 and above, it probably does not matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about diet. For instance, it seems that those who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any clear recommendations.
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 cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, each one the guys had increased levels of testosteronenone reported any side effects during the entire 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 is more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication such as clomiphene citrate one of just a few options for men with low testosterone that want to father children.
What forms of testosterone-replacement therapy can be found? *
The earliest form is the injection, which we use because it's cheap and since we faithfully get good testosterone levels in almost everybody. The disadvantage 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 testosterone levels peak and return to baseline. [See"Exogenous vs. endogenous testosterone," above.]
Topical therapies help preserve a more uniform amount of blood testosterone. The first form of topical treatment has been a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a red area on their skin. That restricts its usage.
The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off with -- is a topical gel. Based on my experience, it has a tendency to be absorbed to good degrees in about 80% to 85% of men, but leaves a substantial number who do not consume enough for it to have a favorable impact. [For specifics on several different formulations, see table ]
Are there any drawbacks to using dyes? How much time does it take for them to get the job done?
Men who begin using the gels have to return in to have their own testosterone levels measured again to make certain they are absorbing the right amount. Our goal is that the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I usually measure it after two weeks, although symptoms may not change for a month or two.