A Harvard expert shares his Ideas on testosterone-replacement therapy
It might be stated that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, big 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 contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels begin to fall, by approximately 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low working and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed issue, with only about 5% of those affected receiving treatment.
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 difficulties. He's developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and he thinks experts should reconsider the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average person to find a doctor?
As a urologist, I tend to observe guys because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something that would usually be arousing.
The more of these symptoms there are, the more probable it is that a man has low testosterone. Many physicians tend to discount 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 men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How do you determine whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways we determine whether someone 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 perfect. Normally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. However, there are some guys who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, 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 is not quite as apparent.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. Is total testosterone the ideal point to be measuring? Or should we be measuring something else? This is another area of confusion and great 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 learned about overall testosterone, or all of the testosterone in the human body. But about half of the testosterone that is circulating in the blood isn't available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Even though it's only a small portion of this overall, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the correlation is greater than with testosterone.
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