The Options For Effortless testosterone therapy Plans

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

It could be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.

As time passes, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning 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's an underdiagnosed issue, with just about 5 percent of those affected receiving treatment.

Much of the current debate focuses on the long-held belief that testosterone may 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 ailments and male reproductive and sexual problems. He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.

Symptoms Resourcesmy siteimportant link and diagnosis

What symptoms and signs of low testosterone prompt the average person to find a doctor?

As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something that would usually be arousing.

The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.

Are not those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are quite a few drugs which may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go along with therapy 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 struggle to get a fantastic 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 reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum 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 purely at the biochemical amounts, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. However, no one really agrees on a number. It is similar to diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy.

Is complete testosterone the right thing to be measuring? Or if we are measuring something else?

Well, this is just another area of confusion and great debate, but I do not think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the body. But about half of their testosterone that is circulating in the bloodstream is not available to cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of overall testosterone is known as free testosterone, and it is readily available to cells. Though it's only a small fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the correlation is greater than with total testosterone.

Endocrine Society recommendations outlined

This professional organization urges testosterone treatment for men who have

Therapy is not recommended for men who have

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

Do time of day, diet, or other factors affect testosterone levels?

For years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature over the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 5 or 6 p.m.

There are a number of very interesting findings about diet. For instance, it seems that those who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear.

Exogenous vs. endogenous testosterone

In the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and 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 weeks, each one of the men had increased levels of testosterone; none reported any side effects throughout the year they were followed.

Since clomiphene citrate is not approved by the FDA for use in males, 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 formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone that want to father children.

Formulations

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

The oldest form is the injection, which we still use since it is inexpensive and since we reliably become good testosterone levels in almost everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to research.

Topical treatments help maintain 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% of people that used the patch developed a red area on their skin. That restricts its use.

The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it has a tendency 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 effect. [For details on various formulations, see table below.]

Are there any downsides to using dyes? How long does it require them to get the job done?

Men who start using the implants need to return in to have their testosterone levels measured again to make certain they are absorbing the right amount. Our goal 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 usually measure it after two weeks, even although symptoms may not change for a month or two.

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