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A Harvard expert shares his Ideas on testosterone-replacement therapy

A meeting with Abraham Morgentaler, M.D.

It might be said that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, 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 aids cognition.

Over time, the testicular"machinery" which produces 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 signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, decreased 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" referring to the testicles). Yet it is an underdiagnosed problem, 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 dangers patients face. Much of the current debate focuses on the long-held belief that testosterone can stimulate prostate cancer.

He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the typical person to see a doctor?

As a urologist, I have a tendency to observe men since they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.

The more of the symptoms there are, the more probable 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.

Are not those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of drugs which may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce 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 surely if somebody has less sex drive or less attention, it's more of a struggle to get a good erection.

How do you decide whether or not a man is a candidate for testosterone-replacement treatment?

There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are a number of men who have reduced levels of testosterone in their blood and have no signs.

Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one quite agrees on a few. It's not like diabetes, in which if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who Visit This Link should and shouldn't receive testosterone therapy.

Is total testosterone the ideal point to be measuring? Or should we be measuring something different?

This is another area of confusion and great discussion, 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 overall testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the blood is not available to the 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 small fraction of this overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with total testosterone.

This professional organization urges testosterone treatment for men who have

  • Reduced levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy Isn't Suggested for men who've

  • Breast or prostate cancer
  • a nodule on the prostate which may be felt during a DRE
  • that a PSA higher than 3 ng/ml without additional evaluation
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV read this heart see failure.

    Do time of day, diet, or other elements influence testosterone levels?

    For many years, the recommendation was to get a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and older over the course of the day. One reported no change in average testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably not enough to influence diagnosis. Most guidelines still say it's important to do the test in the morning, however for men 40 and over, it probably doesn't matter much, as long as they obtain their blood drawn before 6 or 5 p.m.

    There are a number of very interesting findings about diet. For example, it appears that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear.

    Within the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.

    Within four to six weeks, all the guys had increased levels of testosterone; none reported some side effects during the entire year they had been followed.

    Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of carrying it (such as the risk of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone that want to father children.

    What kinds of testosterone-replacement therapy can be found? *

    The oldest form is the injection, which we still use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to baseline. [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 very large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a reddish area on their skin. That restricts its usage.

    The most commonly used testosterone preparation from the United States -- and the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of guys, but leaves a significant number who don't absorb sufficient for it to have a positive impact. [For specifics on various formulations, see table ]

    Are there any downsides to using dyes? How long does it take for them to get the job done?

    Men who begin using the gels have to return in to have their own testosterone levels measured again to make sure they are absorbing the proper amount. Our target is that 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, within a few doses. I normally measure it after 2 weeks, even although symptoms may not change for a month or two.

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