A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" which produces testosterone gradually becomes less powerful, 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 like reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed problem, with only about 5% of these affected undergoing therapy.
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.
Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate diseases and male reproductive and sexual problems. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the typical person to see a doctor?
As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.
The more of the symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to dismiss those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs that may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not usually go together with it , though certainly if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How can you determine whether a person is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are a number of guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one quite agrees on a number. It is not like diabetes, where 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 should and shouldn't receive testosterone therapy. |
Is complete testosterone the right point to be measuring? Or should we be measuring something else?
This is another area of confusion and good debate, but I do not think that it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. But about half of their testosterone that's circulating in the blood is not readily available to the cells.
The biologically available portion of total testosterone is known as free testosterone, and it's readily available to cells. Nearly every lab has a blood test to measure free testosterone. Though it's only a little 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 compared to total testosterone.
This professional organization recommends testosterone treatment for men who have both
- Reduced levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy Isn't recommended for men who've
- Prostate or breast cancer
- a nodule on the prostate which may be felt during a DRE
- a PSA higher than 3 ng/ml without further evaluation
- that a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III or IV heart Get More Info failure.
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 information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in average testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably insufficient to affect diagnosis. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about diet. For instance, it seems that those who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any clear recommendations.
Within the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Depending on the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.
Within four to six months, each one the guys had increased levels of testosteronenone reported any side effects during the year they were followed.
Because clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes medication such as clomiphene citrate one of just a few options for men with low testosterone who want to father children.
FormulationsWhat forms of testosterone-replacement therapy can be found? *
The earliest form is the injection, which we still use because it's cheap and since we faithfully get good 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 may also happen as blood glucose levels peak and then return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical treatments help preserve a more uniform level of blood testosterone. The first kind of topical treatment was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a reddish area in their skin. That limits its use.
The most widely used testosterone preparation from the United States -- and the one I begin almost everyone off -- is a topical gel. There are 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 that leaves a substantial number who do not absorb enough for this to have a positive effect. [For details on various formulations, see table ]
Are there any drawbacks to using dyes? How much time does it take for them to get the job done?
Men who begin using the gels have to return in to have their testosterone levels measured again to be sure they're absorbing the proper amount. Our goal is the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, in just several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.