A Harvard expert shares his thoughts on testosterone-replacement Treatment
It could 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 at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it fosters 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 fall, by about 1 percent per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed issue, with just about 5 percent of those affected undergoing therapy.
Various studies have shown that testosterone-replacement therapy may provide a wide range of advantages for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on 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 can stimulate prostate cancer.
He has developed particular experience 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 he thinks experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average man to see a physician?
As a urologist, I tend to see men because they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally 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're often treatable and reversible by decreasing testosterone levels.
Aren't those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease 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 attention, it's more of a challenge to have a fantastic erection.
How can you determine whether a man is a candidate for testosterone-replacement treatment?
There are just two ways that 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 those two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are a number of guys who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical numbers, The Endocrine Society* considers 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's not like diabetes, where 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 apparent.
| *Notice: The Endocrine Society recommends clinical practice guidelines with her latest blog recommendations for who should and should his explanation not receive testosterone treatment. Is complete testosterone the ideal point to be measuring? Or if we are measuring something different? This is just another area of confusion and good discussion, but I don't think that it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the human body. However, about half of their testosterone that is circulating in the bloodstream is not 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 total testosterone is known as free testosterone, and it is readily available to cells. Even though it's only a small fraction of this overall, the free testosterone level is a fairly good indicator of low testosterone. It's not perfect, but the significance is greater compared to total testosterone.
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 because levels begin to drop after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature within the course of this day. One reported no change in average testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably insufficient to affect diagnosis. Most guidelines still say it is important to perform the evaluation in the morning, however for men 40 and over, it likely does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m. There are some rather interesting findings about diet. By way of example, it appears that individuals that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been studied thoroughly enough to create any recommendations that are clear.
What forms of testosterone-replacement treatment can be found? * The oldest form is an injection, which we use because it is cheap and since we reliably get fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood testosterone 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 therapy has been a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area in their skin. That limits its use. The most commonly 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 men, but leaves a significant number who do not consume sufficient for this to have a favorable impact. [For specifics on various formulations, see table below.] Are there any drawbacks to using gels? How long does it take for them to work? Men who start using the gels have to come back in to have their testosterone levels measured again to be certain they are absorbing the proper quantity. Our goal is that 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, even although symptoms may not alter for a month or two. |