Clarifying Vital Elements For trt

A Harvard expert shares his thoughts on testosterone-replacement therapy

An interview with Abraham Morgentaler, M.D.

It could be said that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. It also fosters the creation of red blood cells, boosts mood, and aids cognition.

Over time, the "machinery" which produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with just about 5% of these affected receiving treatment.

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 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 problems. He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he thinks experts should reconsider the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt the typical man to find a doctor?

As a urologist, I have a tendency to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other 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 orgasms, a much smaller quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something which would usually be arousing.

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

Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of medications that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if a person has less sex drive or less interest, it's more of a struggle to have a good erection.

How can you decide whether a person is a candidate for testosterone-replacement therapy?

There are two ways we determine whether somebody has low 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 guys 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 numbers, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one really agrees on a number. It's not like diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone see this website therapy. For a complete copy of learn the facts here now the guidelines, log on to www.endo-society.org.

Is complete 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 don't think it's as confusing as it appears to be in 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. However, about half of their testosterone that is circulating in the bloodstream is not available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of overall testosterone is known as free testosterone, and it is readily available to cells. Though it's only a small fraction of this overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have

Therapy Isn't Suggested for men who've

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

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

For years, the recommendation has been to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. But the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older over the course of this day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest amount, and probably insufficient to influence identification. Most guidelines nevertheless say it is important to do the test in the morning, however for men 40 and over, it likely doesn't matter much, as long as they get 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 seems that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been studied thoroughly enough to make any recommendations that are clear.

In this article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based on the formulation, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.

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

Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of carrying it (including the probability of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of just a few options for men with low testosterone who want to father children.

What kinds of testosterone-replacement treatment are available? *

The oldest form is the injection, which we use since it is inexpensive and since we faithfully become good testosterone levels in nearly everybody. The drawback is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical treatments help preserve a more uniform level of blood glucose. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a reddish area in their skin. That restricts its usage.

The most widely used testosterone preparation in the United States -- and the one I start almost everyone off with -- is a topical gel. According to my experience, it has a tendency to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb enough for this to have a favorable impact. [For specifics on various formulations, see table below.]

Are there any drawbacks to using gels? How long does it take for them to work?

Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper quantity. Our goal is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, although symptoms may not alter for a month or two.

Leave a Reply

Your email address will not be published. Required fields are marked *