A Harvard expert shares his thoughts on testosterone-replacement therapy
It might be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" that makes testosterone gradually becomes less powerful, and testosterone levels start to drop, by approximately 1 percent per year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like lower sex drive and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with only about 5% of those affected undergoing therapy.
Studies have shown that testosterone-replacement therapy can offer a vast range of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production.
He's developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his patients, and he believes experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the typical man to see a physician?
As a urologist, I have a tendency to observe guys because they have sexual complaints. The primary hallmark of reduced testosterone is reduced 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, like more difficulty achieving an orgasm, less-intense orgasms, a much lesser amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something which would usually be arousing.
The more of the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs which may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally doesn't go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less interest, it is more of a struggle to get a fantastic erection.
How can you decide whether a man is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether somebody 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. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are a number of men 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 to be a entire testosterone level of less than 300 ng/dl, and I think that is a sensible guide. However, no one really agrees on a number. It's similar to 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 isn't quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations summarized." For a complete copy next of these here guidelines, log on to www.endo-society.org. |
Is complete testosterone the ideal point to be measuring? Or if we are measuring something else?
This is another area of confusion and great discussion, but I don't think that it's as confusing as it appears to be from 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. But about half of the testosterone that is circulating in the blood is not readily available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available portion of total testosterone is called free testosterone, and it's readily available to the cells. Though it's just a small fraction of the total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the correlation is greater than with testosterone.
This professional organization urges testosterone therapy for men who have
Therapy Isn't recommended for men who have
- Breast or prostate cancer
- a nodule on the prostate which may be felt during a DRE
- that a PSA higher than 3 ng/ml without additional analysis
- 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 daily, diet, or other elements affect testosterone levels?
For many years, the recommendation has been to receive a testosterone value early in the morning because levels start to drop after 10 or even 11 a.m.. But 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 over the course of this day. One reported no change in average testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a small amount, and probably not enough to influence identification. Most guidelines still say it's important to perform the test in the morning, but for men 40 and over, it likely doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are some rather interesting findings about dietary supplements. For instance, it seems that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been researched thoroughly enough to create any clear recommendations.
Within this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based upon the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and 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 months, each one of the men had increased levels of testosteronenone reported any side effects throughout the year they were followed.
Since clomiphene citrate is not accepted by the FDA for use in males, little information exists regarding the long-term effects of carrying it (such as the probability of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes drugs such as clomiphene citrate one of just a few options for men with low testosterone that wish to father children.
What kinds of testosterone-replacement therapy can be found? *
The oldest form is the injection, which we still use because it is inexpensive and since we faithfully get fantastic testosterone levels in almost everybody. The drawback is that a person should come in every couple of weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to baseline.
Topical treatments help maintain a more uniform level of blood testosterone. The first kind 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 on their skin. That limits its usage.
The most commonly used testosterone preparation from the United States -- and the one I begin almost everyone off with -- 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 has a tendency to be absorbed to good degrees in about 80% to 85 percent of men, but leaves a significant number who don't consume enough for this to have a positive impact. [For specifics on various formulations, see table ]
Are there any downsides to using gels? How much time does it take for them to work?
Men who start using the gels have to return in to have their testosterone levels measured again to make certain they are absorbing the proper quantity. Our goal is that the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, within a few doses. I normally measure it after 2 weeks, even though symptoms may not change for a month or two.