A Harvard Specialist shares his Ideas on testosterone-replacement Treatment
It might be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by approximately 1 percent a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone such as reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms 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 issue, with only about 5% of those affected undergoing therapy.
But little consensus exists about 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 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 sexual and reproductive problems. 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 uses with his patients, and why he believes experts should reconsider the potential link between testosterone-replacement treatment 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 guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something which 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 often discount these"soft symptoms" as a normal part of aging, but they're 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 quite a few drugs that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity usually doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it either, though surely if a person has less sex drive or less interest, it's more of a struggle to have a fantastic erection.
How do you determine if or not a person is a candidate for testosterone-replacement therapy?
There are two ways that 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 those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. But there are some men who have reduced levels of testosterone in their blood and have no signs.
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 is a sensible guide. However, no one really agrees on a few. It is similar to diabetes, in which if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with have a peek at this site recommendations for who should and shouldn't receive testosterone therapy. Is total testosterone the right thing to be measuring? Or should we be measuring something else? Well, this is another area of confusion and great discussion, but I do not think that it's as confusing as it is apparently from 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 available to the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available part of total testosterone is called free testosterone, and it's readily available to cells. Though it's just a small fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.
What forms of testosterone-replacement treatment can be found? * The oldest form is an injection, which we still use since it is cheap and because we reliably get good testosterone levels in nearly everybody. The drawback is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline. [See"Exogenous vs. endogenous testosterone," above.] Topical treatments help preserve a more uniform amount of blood glucose. The first kind of topical therapy was a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area in their skin. That restricts its usage. The most widely used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. 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 this 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 be certain they're absorbing the right amount. Our target is the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, in just several doses. I normally measure it after 2 weeks, though symptoms may not change for a month or two. |