A Harvard expert shares his Ideas on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
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 leads to normal erections. Additionally, it boosts the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like reduced sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with only about 5% of these affected receiving treatment.
Studies have revealed that testosterone-replacement therapy can provide a wide range of advantages for men with hypogonadism, such as 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 sexual and reproductive problems. He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and why he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average man to see a doctor?
As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser 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 these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.
Aren't those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if somebody has less sex drive or less interest, it's more of a challenge to get a good erection.
How do you determine whether a man is a candidate for testosterone-replacement therapy?
There are just two ways we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those 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 some 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. But no one quite agrees on a number. It's similar to diabetes, in which if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. For a complete copy of these instructions, log go to these guys on to www.endo-society.org. Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different? Well, this is another area of confusion and good discussion, but I don't think it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the body. However, about half of their testosterone that's circulating in the blood isn't available to the cells. It is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Even though it's just a small portion of the total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with testosterone.
Do time daily, diet, or other factors influence testosterone levels? For years, the recommendation was to get a testosterone value early in the morning since levels start to fall after 10 or 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of the day. One reported no change in average testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably not enough to influence identification. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and above, it likely does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m. There are a number of rather interesting findings about diet. By way of example, it appears that those 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 make any recommendations that are clear. Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Depending upon the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects. Within four to six months, each one the guys had increased levels of testosteronenone reported any side effects throughout the entire year they had been followed. Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists regarding the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it's 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 wish to father children. What forms of testosterone-replacement therapy are available? * The oldest form is an injection, which we still use since it is cheap and since we faithfully get good testosterone levels in nearly everybody. The disadvantage is that a person should 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 research. [Watch"Exogenous vs. endogenous testosterone," above.] Topical treatments help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a reddish area in their skin. That limits its use. The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off -- is a topical gel. According to my experience, it tends to be absorbed to great levels in about 80% to 85% of guys, but that leaves a substantial number who do not absorb enough for this to have a positive impact. [For details on various 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 start using the gels have to return in to have their own 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, within a few doses. I normally measure it after two weeks, even though symptoms may not change for a month or two. |