A Harvard Specialist shares his thoughts on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It could be said that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by about 1% 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 libido and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low functioning 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's an underdiagnosed problem, with just about 5 percent of those affected undergoing therapy.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 difficulties. He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and he thinks experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical person to see a physician?
As a urologist, I have a tendency to see guys because they have sexual complaints. The primary 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 orgasms, a much smaller amount of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.
The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are a number of drugs that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less interest, it is more of a struggle to get a good erection.
How do you determine if or not a person is a candidate for testosterone-replacement treatment?
There are just 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 approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. However, no one really agrees on a number. It's not like diabetes, where if your fasting glucose 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 for read what he said who should helpful site and should not receive testosterone treatment. Is total testosterone the right point to be measuring? Or if we are measuring something else? Well, this is another area of confusion and great debate, but I don't think 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 the testosterone in the body. But about half of the testosterone that's circulating in the blood isn't readily 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. Even though it's only a small portion of this total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the correlation is greater than with testosterone.
Do time daily, diet, or other elements affect testosterone levels? For years, the recommendation has been to receive a testosterone value early in the morning because 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 glucose levels in men 40 and older over the course of this day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably not enough to affect identification. Most guidelines still say it is important to do the evaluation in the morning, however for men 40 and above, it probably does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m. There are a number of very interesting findings about dietary supplements. For instance, it appears that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to make any clear recommendations. Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending upon the formulation, therapy can cause 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 months, all the men had increased levels of testosterone; none reported any side effects throughout the year they were followed. Since clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it is more capable of boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. That makes medication 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 can be found? * The oldest 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 needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.] Topical treatments help maintain a more uniform level of blood testosterone. The first form of topical therapy has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area on their skin. That restricts its use. The most commonly used testosterone preparation in the United States -- and the one I start almost everyone off with -- is a topical gel. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be consumed to great degrees in about 80% to 85 percent of guys, but leaves a substantial number who don't absorb enough for it to have a positive effect. [For specifics on various formulations, see table below.] Are there any drawbacks to using gels? How long does it require them to get the job done? Men who begin using the implants need to return in to have their own testosterone levels measured again to make sure they're absorbing the right amount. Our target is the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, although symptoms may not alter for a month or two. |