A Harvard expert shares his Ideas on testosterone-replacement therapy
It might be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from girls. It stimulates the development of the genitals , 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 assists cognition.
As time passes, the "machinery" that makes 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 begin to have symptoms and signs of low testosterone like reduced libido and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. 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 illness affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed issue, with just about 5% 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's developed particular expertise 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 he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms click here to readlook at this website and my response diagnosisWhat symptoms and signs of low testosterone prompt that the average person to find a doctor?
As a urologist, I have a tendency to observe men because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other man 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 amount of fluid out of ejaculation, and a sense of numbness in the penis 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 dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of medications that may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though certainly if a person has less sex drive or less interest, it is more of a challenge to have a good erection.
How can you determine if or not a man is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between these two methods is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely 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 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 will say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. |
Is complete testosterone the ideal point to be measuring? Or should we be measuring something else?
This is just another area of confusion and good debate, but I do not think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream is not readily available to cells.
The available part of total testosterone is known as 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 this total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization recommends testosterone therapy for men who have both Therapy Isn't Suggested for men who've
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Do time of day, diet, or other factors affect testosterone levels?
For many years, the recommendation was to get a testosterone value early in the morning because levels start to drop after 10 or 11 a.m.. But the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a small amount, and probably not enough to affect identification. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and above, it likely does not matter much, provided that they get their blood drawn before 5 or 6 p.m.
There are some rather interesting findings about dietary supplements. By way of example, it appears that those that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
Exogenous vs. endogenous testosteroneIn the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Depending 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. Within four to six weeks, each one of the guys had increased levels of testosterone; none reported some side effects during the year they had been followed. Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of carrying it (including the risk of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes drugs such as clomiphene citrate one of only a few options for men with low testosterone that want to father children. What forms of testosterone-replacement treatment are available? * The earliest form is an injection, which we use since it's cheap and because we faithfully get good testosterone levels in almost everybody. The disadvantage is that a person 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. [See"Exogenous vs. endogenous testosterone," above.] Topical therapies help preserve a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a quite large 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 also the one I start almost everyone off -- is a topical gel. According to my experience, it tends to be absorbed to great levels in about 80% to 85 percent of men, but leaves a substantial number who do not absorb sufficient for it to have a positive impact. [For specifics on several different 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 return in to have their testosterone levels measured again to be certain they're absorbing the right quantity. Our goal is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just several doses. I normally measure it after two weeks, even although symptoms may not change for a month or two. |