A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It could be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. 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 start to fall, by approximately 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 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 functioning and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with only about 5% of these affected undergoing therapy.
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 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 specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and why he believes specialists should rethink the potential link 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 tend to see men because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller amount of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally be arousing.
The more of the symptoms you will find, 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 decreasing testosterone levels.
Are not those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally 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 is more of a challenge to have a good erection.
How can you determine if a person is a candidate for testosterone-replacement therapy?
There are 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 ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really agrees on a number. It is not like diabetes, in which if your fasting glucose 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 who should and shouldn't receive testosterone treatment. |
Is complete testosterone the right point to be measuring? Or should we be measuring something else?
Well, this is just another area of confusion and good debate, but I do not think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream is not 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 is readily available to cells. Though it's just a small fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with total testosterone.
Endocrine Society recommendations summarizedThis professional organization recommends testosterone therapy for men who have both
Therapy is not recommended for men who've
|
What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we use since it's cheap and because we faithfully get 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 return to baseline. [See"Exogenous vs. endogenous testosterone," above.]
Topical treatments help maintain a more uniform level of blood testosterone. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a red area in 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. The gel comes in tiny tubes or in a unique 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 degrees in about 80% to 85% of men, but leaves a significant number who don't absorb sufficient for this to have a positive impact. [For specifics on several different formulations, see table ]
Are there any downsides to using gels? How long does it require them to work?
Men who start using the gels have to return in to have their own testosterone levels measured again to make certain they are absorbing the right amount. Our goal is that the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, in just a few doses. I usually measure it after two weeks, even although symptoms may not change for a month or two.