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A Harvard expert shares his Ideas on testosterone-replacement Treatment

 

An interview with Abraham Morgentaler, M.D.

It might be stated that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from women. It stimulates the development 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 gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% per year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called 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 receiving treatment.

But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. 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 plans he uses with his patients, and he thinks experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt that the average person to see a physician?

As a urologist, I tend to observe guys because they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much lesser amount 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 the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often discount these"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 are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of medications which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity usually doesn't go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if a person has less sex drive or less interest, it's more of a struggle to have a good erection.

How do you decide if a man is a candidate for testosterone-replacement therapy?

There are just two ways we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and guys 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* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. However, no one really agrees on a number. It's not like diabetes, where if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't Your Domain Name receive testosterone therapy. For a complete copy try this website of these instructions, log on to www.endo-society.org.

Is total testosterone the right thing to be measuring? Or if we are measuring something different?

This is just another area of confusion and good discussion, but I do not think it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they heard about overall 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. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of total testosterone is called free testosterone, and it's readily available to the cells. Though it's just a small fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.

This professional organization recommends testosterone treatment for men who have

  • Reduced levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy Isn't Suggested for men who have

  • Prostate or breast cancer
  • a nodule on the prostate which may be felt during a DRE
  • that a PSA greater than 3 ng/ml without additional analysis
  • that a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure.

    Do time of day, diet, or other elements influence testosterone levels?

    For years, the recommendation has been 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 testosterone levels in men 40 and mature over the course of this day. One reported no change in typical testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably not enough to influence identification. Most guidelines still say it's important to perform the test in the morning, however for men 40 and above, 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. 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 researched thoroughly enough to make any clear recommendations.

    Exogenous vs. endogenous testosterone

    In the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based on the formula, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.

    Within four to six months, all the guys had increased levels of testosterone; none reported some side effects during the entire year they had been followed.

    Because clomiphene citrate isn't accepted by the FDA for use in men, little information exists regarding the long-term effects of carrying it (including the risk of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes medication such as clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.

    Formulations

    What kinds of testosterone-replacement treatment can be found? *

    The oldest form is an injection, which we use because it is cheap and because we reliably become good 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 may also happen as blood glucose levels peak and then return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help preserve a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of men who used the patch developed a reddish area in their skin. That restricts its usage.

    The most commonly used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. According to my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb enough for it to have a positive effect. [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 certain they're 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 really goes up quite fast, in just several doses. I normally measure it after 2 weeks, though symptoms may not change for a month or two.

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