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A Harvard Specialist shares his Ideas on testosterone-replacement Treatment

An interview with Abraham Morgentaler, M.D.

It might be stated 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 , plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.

As time passes, the "machinery" which produces testosterone slowly becomes less effective, and testosterone levels begin to drop, by about 1 percent per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working 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 only about 5 percent of those affected receiving treatment.

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 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 ailments and male reproductive and sexual difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and why he believes specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt that the average man 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 libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser amount of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.

The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss these"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 guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce 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 surely if a person has less sex drive or less attention, it is more of a challenge to get a good erection.

How can you decide if or not a man 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 one is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess 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 few. It is similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment.

Is total testosterone the right point to be measuring? Or if we are measuring something different?

This is just another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently from the literature. When most doctors 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 closely 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 the cells. Even though it's only a little portion of this total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the correlation is greater than with total testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone therapy for men who have

Therapy is not recommended for men who've

  • Breast or prostate cancer
  • a nodule on the prostate which can be felt during a DRE
  • that a PSA higher than 3 ng/ml without further evaluation
  • that a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV link heart why not try here failure.

    Do time daily, diet, or other factors affect testosterone levels?

    For many years, the recommendation was to get a testosterone value early in the morning because levels start to fall after 10 or even 11 a.m.. But the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature within the course of the day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a modest amount, and probably insufficient to affect identification. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and above, it likely doesn't 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 diet. By way of example, it seems that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to make any clear recommendations.

    Exogenous vs. endogenous testosterone

    Within the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.

    Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, also known as endogenous testosterone, in men. Within four to six months, all of the guys had increased levels of testosteronenone reported some side effects throughout the year they had been followed.

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

    What forms of testosterone-replacement treatment are available? *

    The earliest form is an injection, which we use since it is inexpensive and because we reliably become fantastic testosterone levels in nearly everybody. The disadvantage is that a man should come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help preserve a more uniform level of blood testosterone. The first form of topical therapy was 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 limits its use.

    The most commonly used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. According to my experience, it has a tendency to be absorbed to good levels in about 80% to 85% of men, but that 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 take for them to work?

    Men who start using the gels have to come back in to have their testosterone levels measured again to make sure they're absorbing the right amount. Our target 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, within a few doses. I usually measure it after 2 weeks, even although symptoms may not alter for a month or two.

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