A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It could be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, 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 about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they might begin 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 nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.
Studies have revealed that testosterone-replacement therapy may offer a vast selection of advantages for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 problems. He's developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his patients, and he thinks experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical man to see a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should possess his testosterone level checked. Men may experience other symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much smaller quantity 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 often dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing 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, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity usually doesn't go along with treatment 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 person is a candidate for testosterone-replacement therapy?
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 these two methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some men 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 entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one quite agrees on a few. It's similar to diabetes, in which if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive find testosterone treatment. For a complete copy of these guidelines, log on click here to find out more to www.endo-society.org. Is total testosterone the ideal point to be measuring? Or should we be measuring something different? Well, this is just another area of confusion and good discussion, but I don't think it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the human body. However, about half of the testosterone that's circulating in the blood isn't 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 part of total testosterone is called free testosterone, and it is readily available to cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater compared to total testosterone.
What kinds of testosterone-replacement treatment are available? * The earliest form is an injection, which we use since it is inexpensive and since we reliably become good testosterone levels in almost everybody. The disadvantage is that a person should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and then return to research. [See"Exogenous vs. endogenous testosterone," above.] Topical treatments help preserve a more uniform level of blood testosterone. The first kind of topical therapy has been a patch, but it has a quite high 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 limits its usage. The most widely used testosterone preparation from the United States -- and the one I begin almost everyone off -- is a topical gel. According to my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of men, but leaves a significant number who do not absorb enough for this to have a favorable effect. [For details on several different formulations, see table below.] Are there any downsides to using dyes? 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 sure they're absorbing the right amount. Our goal is the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, within several doses. I normally measure it after 2 weeks, even though symptoms may not change for a month or two. |