A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It might be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from women. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and aids cognition.
As time passes, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels start to drop, by about 1% a year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone like reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5 percent of these affected undergoing therapy.
Various studies have revealed that testosterone-replacement therapy may provide a vast range of benefits for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists about 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 may 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 difficulties. He's 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 patients, and why he thinks experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average man to see a physician?
As a urologist, I have a tendency to see guys since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much smaller quantity of fluid out of ejaculation, and a sense 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 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 medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not ordinarily go along with it , though certainly if somebody has less sex drive or less interest, it's more of a challenge to get a good erection.
How can you determine whether or not a person is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are some men who have reduced 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's a reasonable guide. However, no one really 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 is not quite as clear.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for more information who should and should not receive testosterone therapy. Is total testosterone the right point to be measuring? Or should we be measuring something different? Well, this is just another area of confusion and good discussion, but I don't think it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. However, about half of their testosterone that is circulating in the blood is not available to the cells. It's tightly bound to a carrier molecule called 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 the cells. Even though it's just a little portion of this total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not ideal, but the significance is greater than with testosterone.
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