Essential Factors Of hrt Revealed

A Harvard expert shares his thoughts on testosterone-replacement therapy

It might be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from women. It stimulates the growth 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 aids cognition.

As time passes, the "machinery" that produces testosterone slowly becomes less powerful, and testosterone levels start to drop, by approximately 1% per year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like lower libido and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with only about 5 percent of those affected receiving treatment.

Studies have shown that testosterone-replacement therapy can provide a vast range of benefits for men with hypogonadism, including 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 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 diseases and male sexual and reproductive problems. He's developed particular expertise 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 potential connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the typical person to find a physician?

As a urologist, I have a tendency to observe men 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 must get his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense orgasms, a lesser quantity 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, but they're often treatable and reversible by normalizing testosterone levels.

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

Not exactly. There are a number of medications that may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally doesn't go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if somebody has less sex drive or less attention, it is more of a challenge to get a fantastic erection.

How can you decide if or not a person is a candidate for testosterone-replacement treatment?

There are just two ways that we determine whether someone has reduced 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 guys with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are some men who have reduced levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. But no one really agrees on a few. It's 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 is not quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive you could try here testosterone treatment. For a complete copy of the instructions, log on look here to www.endo-society.org.

Is complete testosterone the ideal point to be measuring? Or if we are measuring something else?

This is just another area of confusion and good debate, 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 heard about overall testosterone, or all of the testosterone in the human body. However, about half of the testosterone that is circulating in the bloodstream isn't readily available to cells. It is tightly 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 is readily available to the cells. Though it's only a small portion of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not ideal, but the significance is greater than with total testosterone.

This professional organization urges testosterone treatment for men who have both

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

Therapy Isn't recommended for men who have

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • that a PSA greater 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 heart failure.

Do time daily, diet, or other elements influence testosterone levels?

For years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of the day. One reported no change in typical testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a small sum, and probably insufficient to influence diagnosis. Most guidelines still say it's important to do the evaluation in the morning, but for men 40 and over, it probably doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m.

There are some very interesting findings about diet. For example, it appears that individuals who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been researched thoroughly enough to make any recommendations that are clear.

Exogenous vs. endogenous testosterone

In the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending on the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, known as nitric oxide, in men. Within four to six weeks, all the men had heightened levels of testosteronenone reported any side effects during the entire year they had been followed.

Since 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 probability of developing prostate cancer) or if it is more effective at boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enriches -- sperm production. This makes medication such as clomiphene citrate one of just a few options for men with low testosterone that wish to father children.

Formulations

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

The earliest form is the injection, which we use since 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 glucose levels peak and return to baseline.

Topical therapies help maintain a more uniform level of blood testosterone. The first form of topical therapy has been a patch, but it has a quite high rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area on their skin. That limits its use.

The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes in miniature tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be consumed to good degrees in about 80% to 85% of guys, but that leaves a substantial number who do not consume sufficient for this to have a positive impact. [For details on various formulations, see table ]

Are there any downsides to using gels? How much time does it take for them to work?

Men who begin using the gels have to come back in to have their testosterone levels measured again to be sure they're absorbing the right amount. Our goal is that the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within several doses. I usually measure it after 2 weeks, though symptoms may not change for a month or two.

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