No-Fuss hrt Plans

A Harvard expert shares his thoughts on testosterone-replacement therapy

A meeting with Abraham Morgentaler, M.D.

It could be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big 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. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.

As time passes, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels begin to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive 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" significance low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.

Various studies have revealed that testosterone-replacement therapy can offer a wide 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 can stimulate prostate cancer.

He's developed specific experience 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 possible link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt that the average person to find a physician?

As a urologist, I tend to see guys since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much lesser 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 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 men 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 decrease the quantity of the ejaculatory fluid, no question. However 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's more of a struggle to have a good erection.

How can you determine if a man is a candidate for testosterone-replacement treatment?

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 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 symptoms.

Looking at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. However, no one quite agrees on a number. It is similar to diabetes, where if your fasting sugar 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 recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. Watch"Endocrine Society recommendations summarized." click to read For a complete copy of these guidelines, log on to Visit Your URL www.endo-society.org.

Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?

Well, this is another area of confusion and great discussion, but I do not 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 the testosterone in the human body. However, about half of their testosterone that's circulating in the blood isn't readily available to the 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 the cells. Though it's only a small fraction of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have

Therapy is not recommended for men who have

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

    Do time daily, diet, or other elements influence testosterone levels?

    For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to influence diagnosis. Most guidelines still say it's important to perform the evaluation in the morning, however for men 40 and above, it probably doesn't matter much, provided that they obtain their blood drawn before 6 or 5 p.m.

    There are a number of rather interesting findings about dietary supplements. By way of instance, it appears that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear.

    In the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Depending upon the formula, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

    Within four to six months, all the guys had increased levels of testosterone; none reported some side effects during the year they had been followed.

    Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of carrying it (including the risk of developing prostate cancer) or if it is more capable of boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children.

Formulations

What forms of testosterone-replacement treatment can be found? *

The oldest form is the injection, which we still use since it's cheap and because we faithfully get good testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also occur as blood glucose levels peak and then return to research. [See"Exogenous vs. endogenous testosterone," above.]

Topical treatments help maintain a more uniform amount of blood testosterone. The first kind 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 in their skin. That limits its usage.

The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. The gel comes from miniature tubes or within 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 great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb enough for this to have a favorable impact. [For details on several different formulations, see table ]

Are there any downsides to using gels? How long does it require them to get the job done?

Men who start using the gels have to return in to have their own testosterone levels measured again to make sure they're absorbing the proper amount. Our target is that the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within a few doses. I normally measure it after two weeks, though symptoms may not alter for a month or two.

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