Picking Out Effective Methods For testosterone therapy

A Harvard Specialist shares his Ideas on testosterone-replacement Treatment

 

An interview with Abraham Morgentaler, M.D.

It might be said that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing 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 production of red blood cells, boosts mood, and aids cognition.

As time passes, the testicular"machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower sex drive and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, with just about 5 percent of those affected undergoing therapy.

Various studies have shown that testosterone-replacement therapy may provide a vast range of benefits for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 sexual and reproductive difficulties. He's developed specific 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 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 average man to see a physician?

As a urologist, I have a tendency to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.

The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.

Aren't those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications which 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 question. But a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less attention, it's more of a challenge to get a good erection.

How do you decide if or not a man is a candidate for testosterone-replacement therapy?

There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are some guys who have reduced levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe 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 will say,"Okay, you've got it." With testosterone, that break point is not quite as clear.

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

Is complete testosterone the right thing to be measuring? Or if we are measuring something else?

Well, this is just another area of confusion and great debate, but I do not think it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of their testosterone that's circulating in the blood is not readily available to the cells. It is tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of total testosterone is called free testosterone, and it is readily available to the cells. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone therapy for men who have

Therapy is not Suggested for men who have

  • Breast or prostate cancer
  • a nodule on the prostate that can be felt during a DRE
  • that a PSA greater than 3 ng/ml without additional evaluation
  • that a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV Click Here heart failure.

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

    For many years, the recommendation has been to receive a testosterone value early in the morning since levels start to fall after 10 or 11 a.m.. But the information behind that recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and older within the course of this day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a small sum, and probably not enough to influence identification. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and over, it likely doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m.

    There are some rather interesting findings about dietary supplements. For example, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to make any clear recommendations.

    Exogenous vs. endogenous testosterone

    In the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based upon the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.

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

    Since clomiphene citrate isn't accepted by the FDA for use in men, little information exists about the long-term effects of taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone that want to father children.

    What forms of testosterone-replacement therapy are available? *

    The oldest form is an injection, which we use since it is cheap and because we reliably get good testosterone levels in nearly everybody. The disadvantage is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help maintain a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a quite high rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area in their skin. That restricts its usage.

    The most commonly used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. Based on my experience, it tends to be consumed to great levels in about 80% to 85% of guys, but leaves a substantial number who do not consume sufficient for it to have a positive impact. [For details on several different formulations, see table below.]

    Are there any drawbacks to using dyes? How much time does it take for them to get the job done?

    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 proper quantity. Our target is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within several doses. I normally measure it after two weeks, even though symptoms may not alter for a month or two.

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