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A Harvard expert shares his Ideas on testosterone-replacement therapy

It might be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing 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 boosts the creation of red blood cells, boosts mood, and assists cognition.

As time passes, the "machinery" that makes testosterone gradually becomes less effective, and testosterone levels begin to drop, by approximately 1 percent a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as lower libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, 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 diseases and male sexual and reproductive difficulties. He has 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 potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get 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 these 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, however, they are often treatable and reversible by decreasing testosterone levels.

Aren't those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though surely if somebody has less sex drive or less attention, it is more of a challenge to have a fantastic erection.

How do you decide whether 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 ideal. Generally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are a number of men who have reduced levels of testosterone in their blood and have no symptoms.

Looking 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. But no one really agrees on a number. It is not like diabetes, where if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society publishes clinical practice guidelines with a knockout post recommendations for who should and Related Site should not receive testosterone therapy.

Is complete testosterone the ideal thing to be measuring? Or if we are measuring something else?

Well, this is just another area of confusion and great debate, but I do not think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. However, about half of the testosterone that's circulating in the blood isn't available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available portion of overall testosterone is called free testosterone, and it's readily available to cells. Even though it's only a small fraction of this overall, the free testosterone level is a fairly good indicator of low testosterone. It's not perfect, but the significance is greater compared to testosterone.

Endocrine Society recommendations outlined

This professional organization recommends testosterone therapy for men who have

Therapy Isn't Suggested for men who have

  • Breast or prostate cancer
  • a nodule on the prostate that can be felt during a DRE
  • a PSA higher than 3 ng/ml without further analysis
  • that a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure. click here for more info

    Do time of day, diet, or other factors affect testosterone levels?

    For years, the recommendation has been to receive a testosterone value early in the morning since levels begin to drop after 10 or 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 over the course of the day. One reported no change in average testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.

    There are a number of very interesting findings about diet. For example, it seems that individuals 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 clear recommendations.

    Exogenous vs. endogenous testosterone

    Within this article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based upon the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects.

    In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six months, all the men had increased levels of testosteronenone reported some side effects during the entire year they had been followed.

    Because clomiphene citrate isn't accepted by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the risk 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 only a few options for men with low testosterone that want to father children.

    What kinds of testosterone-replacement therapy can be found? *

    The oldest form is the injection, which we still use since it's cheap and because we faithfully get fantastic 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 testosterone levels peak and then return to research.

    Topical treatments help maintain a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area on their skin. That restricts its use.

    The most widely used testosterone preparation from the United States -- and the one I begin almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. Based on 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 positive effect. [For details on several different formulations, see table below.]

    Are there any downsides to using dyes? 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 are 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, in just a few doses. I normally measure it after 2 weeks, even though symptoms may not change for a month or two.

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