An interview with Abraham Morgentaler, M.D.
It could be stated that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large 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. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" which makes testosterone slowly becomes less effective, and testosterone levels start to drop, by about 1% per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin 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 called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of those affected receiving treatment.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 has 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 he thinks experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.Symptoms read the article and important link diagnosis
What symptoms and signs of low testosterone prompt the typical man to see a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a much smaller quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians tend to dismiss those"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.
Aren't those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs which may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce 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 usually go along with it , though surely if a person has less sex drive or less interest, it is more of a challenge to get a good erection.
How do you decide if or not a man is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two methods is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone for a total testosterone level of less than 300 ng/dl, and I think that is a sensible guide. But no one really agrees on a few. It's not like diabetes, where if your fasting glucose is over 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.|
Is total testosterone the ideal point to be measuring? Or if we are measuring something different?
This is just another area of confusion and great debate, but I don't think it's as confusing as it appears to be in the literature. When most physicians 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 readily available to cells. It's tightly bound to a carrier molecule called 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. Though it's only a small fraction of the total, the free testosterone level is a fairly good indicator of low testosterone. It's not perfect, but the correlation is greater than with total testosterone.
Endocrine Society recommendations outlined
This professional organization recommends testosterone therapy for men who have
Therapy is not Suggested for men who have
Do time daily, diet, or other elements affect testosterone levels?
For many years, the recommendation was to get a testosterone value early in the morning because levels begin to drop after 10 or even 11 a.m.. However, 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 older over the course of this day. One reported no change in average testosterone until after 2 Between 6 and 2 p.m., it went down by 13%, a small amount, and probably not enough to affect diagnosis. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and over, it probably does not 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 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.
Exogenous vs. endogenous testosterone
Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Based on the formula, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all of the guys had heightened levels of testosteronenone reported any side effects throughout the entire year they were followed.
Since clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term effects of carrying it (such as the risk of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone that wish to father children.
What kinds of testosterone-replacement therapy can be found? *
The earliest form is an injection, which we still use since it's cheap and since we reliably get fantastic testosterone levels in nearly everybody. The disadvantage is that a person should come in every few weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to research.
Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a reddish area on their skin. That limits its use.
The most commonly used testosterone preparation in the United States -- and the one I begin almost everyone off -- is a topical gel. Based on my experience, it tends to be absorbed to great levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb 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 get the job done?
Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are 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 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.