A Harvard expert shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" that produces testosterone slowly becomes less effective, and testosterone levels begin to drop, by about 1% per year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone such as lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed issue, with only about 5% of these affected receiving treatment.
Various studies have shown that testosterone-replacement therapy may offer a vast selection of advantages for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
He has developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his own patients, and why he believes experts should reconsider the possible link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average person to find a doctor?
As a urologist, I have a tendency to see men because they have sexual complaints. The main hallmark of reduced testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would usually 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 these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs which may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go along with therapy for BPH. Erectile dysfunction does not usually go along with it , though surely if a person has less sex drive or less attention, it is more of a challenge to have a good erection.
How can you determine whether a man is a candidate for testosterone-replacement therapy?
There are just two ways we determine whether somebody has reduced 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. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, 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* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I think that is a sensible guide. But no one quite agrees on a few. It is not like diabetes, where if your fasting sugar is over 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 visit this web-site for who should and should not receive testosterone treatment. Is total testosterone the right point to be measuring? Or if we are measuring something different? Well, this is just another area of confusion and good discussion, but I don't think it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the human body. However, about half of the testosterone that is circulating in the bloodstream isn't available to cells. The available part of total testosterone is known as free testosterone, and it's readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's just a small portion of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not ideal, but the correlation is greater than with total testosterone. This professional organization recommends testosterone treatment for men who have both
Therapy Isn't recommended 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 fall after 10 or even 11 a.m.. But the information behind that 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 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 percent, a modest sum, and probably not enough to affect diagnosis. Most guidelines still say it is important to do the test in the morning, but for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about diet. By way of example, it appears that those that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear.
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based 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 additional side effects.
Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the creation of natural testosterone, known as nitric oxide, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six months, all the men had increased levels of testosterone; none reported some side effects during the entire year they were followed.
Since clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. This makes medication like clomiphene citrate one of only a few choices for men with low testosterone who want to father children.
FormulationsWhat kinds of testosterone-replacement treatment are available? *
The oldest form is an injection, which we still use since it is inexpensive and since we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a person should come in every few weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to research.
Topical treatments help maintain a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area in their skin. That restricts its use.
The most widely used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it has a tendency to be absorbed to good degrees in about 80% to 85% of guys, but that leaves a significant number who don't absorb sufficient for it to have a favorable impact. [For details on various formulations, see table below.]
Are there any drawbacks to using gels? How much time does it take for them to get the job done?
Men who begin using the implants need to return in to have their testosterone levels measured again to make certain they're absorbing the proper amount. Our target is the mid to upper assortment 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 usually measure it after two weeks, even although symptoms may not alter for a month or two.