A Harvard expert shares his Ideas on testosterone-replacement therapy
It might be stated that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from women. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that makes testosterone slowly becomes less effective, and testosterone levels start to fall, by about 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like reduced libido and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with just about 5 percent of these affected receiving treatment.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face.
He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and he believes experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical man to see a physician?
As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of low testosterone is low 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 different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser amount of fluid out of 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 likely it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. 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 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 certainly if a person has less sex drive or less interest, it is more of a challenge to have a good erection.
How can you decide whether or not a man is a candidate for testosterone-replacement therapy?
There are just two ways that we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between these two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. But there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that is a sensible guide. But no one really agrees on a few. It's similar to diabetes, in which if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone visit this web-site therapy. Watch"Endocrine Society recommendations summarized." For a complete copy of the guidelines, log on i loved this to www.endo-society.org. look here Is complete testosterone the ideal thing to be measuring? Or if we are measuring something else? This is just another area of confusion and great discussion, but I don't think that it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream is not readily 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 called free testosterone, and it's readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's just a little portion of this overall, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the significance is greater than with total testosterone.
Do time of day, diet, or other factors affect testosterone levels? For years, the recommendation has been to get a testosterone value early in the morning because levels begin to drop after 10 or even 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines nevertheless say it's important to do the test in the morning, but for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 5 or 6 p.m. There are some rather interesting findings about dietary supplements. By way of example, it appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.
What kinds of testosterone-replacement therapy can be found? * The earliest form is an injection, which we use since it's cheap and because we reliably become good testosterone levels in almost everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to research. Topical therapies help preserve a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a quite high 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. The gel comes in tiny tubes or in a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be consumed to good levels in about 80% to 85 percent of men, but leaves a significant number who do not absorb sufficient for it to have a positive effect. [For details 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 start using the gels have to return in to have their testosterone levels measured again to make certain they are absorbing the right amount. Our goal is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within a few doses. I normally measure it after two weeks, although symptoms may not change for a month or two. |