A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It might be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" that makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by about 1 percent a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like 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" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed issue, with only about 5% of those affected undergoing therapy.
He's developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and he thinks specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms useful content and discover this diagnosisWhat symptoms and signs of low testosterone prompt the average man to find a physician?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must 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 likely it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs which may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it either, though certainly if a person has less sex drive or less interest, it is more of a struggle to get a good erection.
How do you decide whether or not a person is a candidate for testosterone-replacement treatment?
There are 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 guys with highest testosterone possess the least. But there are a number of guys who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. But no one quite agrees on a few. It's similar to diabetes, in which if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. |
Is total testosterone the right thing to be measuring? Or should we be measuring something else?
Well, this is another area of confusion and great discussion, but I don't think that it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. But about half of the testosterone that's circulating in the blood is not available to cells.
The biologically available part of total testosterone is called free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Though it's just a little portion of the total, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the correlation is greater than with testosterone.
Endocrine Society recommendations summarizedThis professional organization recommends testosterone treatment for men who have both
Therapy is not recommended for men who have
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Do time daily, diet, or other elements influence testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning since levels start to fall after 10 or 11 a.m.. But the information 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 2 and 6 p.m., it went down by 13%, a small amount, and probably not enough to affect identification. Most guidelines still say it is important to perform the evaluation in the morning, however for men 40 and over, it likely does not matter much, as long as they obtain their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about diet. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to make any recommendations that are clear.
Exogenous vs. endogenous testosteroneWithin the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Depending on the formula, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects. Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, also termed nitric oxide, in men. Within four to six weeks, each one of the guys had increased levels of testosteronenone reported any side effects during the entire year they had been followed. Since clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the risk of developing prostate cancer) or if it is more capable of boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few choices for men with low testosterone who want to father children. |
What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we still use since it's inexpensive and because we reliably get good testosterone levels in almost everybody. The disadvantage is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood glucose levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical treatments help preserve a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a quite 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 limits its usage.
The most widely used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes in miniature tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be consumed to good levels in about 80% to 85% of men, but that leaves a substantial number who do not consume sufficient for this to have a favorable effect. [For specifics on various formulations, see table below.]
Are there any downsides to using dyes? How much time does it take for them to work?
Men who begin using the implants need to come back in to have their own testosterone levels measured again to be certain they're absorbing the right amount. Our target is that the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, in just several doses. I normally measure it after two weeks, even although symptoms may not alter for a month or two.