A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It could be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to drop, by about 1 percent per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone such as lower sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs 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 USA. Yet it's an underdiagnosed problem, with only about 5% of these affected undergoing therapy.
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 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 difficulties. He's developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his own patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms useful content and diagnosisWhat signs and symptoms of low testosterone prompt the average person to find a doctor?
As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any 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 climaxes, a much lesser quantity of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something that would normally be arousing.
The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs which may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally does not go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How can you determine whether or not a person is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether someone has reduced 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. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are some guys who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a few. It's not like diabetes, in which if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. |
Is complete testosterone the right point to be measuring? Or if we are measuring something else?
This is another area of confusion and good debate, but I do not think that it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream isn't available to cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.
The available portion of total testosterone is known as free testosterone, and it's readily available to the cells. Even though it's just a small portion of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater than with testosterone.
Endocrine Society recommendations summarizedThis professional organization urges testosterone therapy for men who have both Therapy is not Suggested for men who have
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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 since levels begin to drop after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in average testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a small sum, and probably not enough to influence diagnosis. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of rather interesting findings about diet. For example, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been studied thoroughly enough to make any recommendations that are clear.
Exogenous vs. endogenous testosteroneIn this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending on the formulation, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased 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 months, each one of the men had heightened levels of testosterone; none reported any side effects during the year they were followed. Because clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children. What forms of testosterone-replacement treatment can be found? * The earliest form is an injection, which we still use because it is cheap and since we reliably get good testosterone levels in almost everybody. The drawback is that a person should come in every few weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to research. Topical treatments help maintain 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 people that used the patch developed a red area on their skin. That restricts its usage. The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off with -- is a topical gel. According to my experience, it tends to be absorbed to great levels in about 80% to 85 percent 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 gels? How much time does it require them to work? Men who begin using the gels have to come back in to have their own testosterone levels measured again to make sure they are absorbing the right quantity. Our target is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, within several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two. |