A meeting with Abraham Morgentaler, M.D.
It might 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 girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to drop, by approximately 1% per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like lower libido and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance 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 is an underdiagnosed problem, with only about 5 percent of those affected receiving treatment.
Various studies have revealed that testosterone-replacement therapy can provide a vast range of benefits for men with hypogonadism, including 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.
He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and why he believes experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.Symptoms find and Going Here diagnosis
What signs and symptoms of low testosterone prompt the typical person to find a physician?
As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must possess his testosterone level checked. Men may experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser quantity of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something which would usually be arousing.
The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity usually doesn't go together with treatment for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How do you decide if a person is a candidate for testosterone-replacement therapy?
There are just two ways that we determine whether someone has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between these two approaches is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are some guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. However, no one quite agrees on a few. It is similar to diabetes, in which if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
|*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy.|
Is total testosterone the right point to be measuring? Or should we be 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 learned about total testosterone, or all of the testosterone in the human body. But about half of their testosterone that is circulating in the blood isn't available to the cells.
The biologically available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Even though it's just a small fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the correlation is greater than with total testosterone.
Endocrine Society recommendations summarized
This professional organization recommends testosterone treatment for men who have
Therapy is not recommended for men who've
Do time of day, diet, or other elements affect testosterone levels?
For many years, the recommendation has been to receive a testosterone value early in the morning since levels begin to fall after 10 or 11 a.m.. But the data behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and older within the course of the day. One reported no change in average testosterone until after 2 Between 2 and 6 p.m., it went down by 13%, a small amount, and probably not enough to influence diagnosis. Most guidelines still say it is important to do the test in the morning, but for men 40 and over, it probably doesn't matter much, provided that they obtain their blood drawn before 6 or 5 p.m.
There are some very interesting findings about dietary supplements. By way of instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to create any clear recommendations.
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending on the formula, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional 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 of the guys had heightened levels of testosterone; none reported any side effects during the year they were followed.
Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists about the long-term effects of carrying it (including the probability of developing prostate cancer) or if it's more effective at boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enhances -- sperm production. This makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.Formulations
What kinds of testosterone-replacement therapy can be found? *
The oldest form is the injection, which we use because it's cheap and because we reliably get good testosterone levels in nearly everybody. The drawback is that a person should come in every couple of weeks to find a shot. A roller-coaster effect can also happen as blood glucose levels peak and then return to research. [See"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 very large 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 widely used testosterone preparation from the United States -- and also the one I begin almost everyone off with -- is a topical gel. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, 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 much time does it require them to work?
Men who start using the implants need to come back in to have their own testosterone levels measured again to make sure they're absorbing the right amount. Our goal is the mid to upper assortment of normal, which usually means approximately 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 although symptoms may not alter for a month or two.