Major Elements Of testosterone therapy - An Intro
A meeting with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating 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 drop, 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 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" meaning 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 just about 5% of those affected receiving treatment.
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.
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 reproductive and sexual difficulties. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he thinks experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.Symptoms and diagnosis
What signs and symptoms of low testosterone prompt the typical man to see a physician?
As a urologist, I have a tendency to see guys since they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians tend to dismiss those"soft symptoms" as a normal part of aging, but they're 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 a number of medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go along 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 decide whether 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 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 amounts, The Endocrine Society* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. However, no one quite agrees on a few. It is not like diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
|*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive check over here testosterone treatment. For a complete Learn More copy of the instructions, log on my explanation to www.endo-society.org.|
Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?
This is another area of confusion and great discussion, but I do not think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the body. But about half of their testosterone that is circulating in the bloodstream is not readily available to 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 is readily available to cells. Almost every lab has a blood test to measure free testosterone. Though it's just a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater than with total testosterone.
This professional organization urges testosterone treatment for men who have
- Low levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not recommended for men who have
- Prostate or breast cancer
- a nodule on the prostate that can be felt during a DRE
- a PSA greater than 3 ng/ml without further evaluation
- a hematocrit greater than 50% or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III or IV heart failure.
Do time of day, diet, or other factors 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 information 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 amount, and probably not enough 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 5 or 6 p.m.
There are some very interesting findings about diet. By way of example, it seems that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been studied thoroughly enough to make any clear recommendations.
Exogenous vs. endogenous testosterone
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, each one of the guys had increased levels of testosterone; none reported some side effects during the entire year they had been followed.
Because clomiphene citrate isn't approved by the FDA for use in males, little information exists about the long-term effects of carrying it (including the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone who wish to father children.
What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we use since it's cheap and because we reliably become 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 happen as blood glucose levels peak and then return to research.
Topical treatments help maintain a more uniform amount of blood testosterone. The first form of topical treatment was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a red area in their skin. That limits its use.
The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes from miniature tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be absorbed to good degrees in about 80% to 85 percent of men, but leaves a substantial number who do not absorb enough for this to have a favorable effect. [For specifics on several different formulations, see table below.]
Are there any drawbacks to using dyes? How much time does it take for them to work?
Men who begin using the implants need to come back in to have their testosterone levels measured again to be certain they are absorbing the right amount. Our target is the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, in just several doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two.