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A Harvard Specialist shares his Ideas on testosterone-replacement Treatment

A meeting with Abraham Morgentaler, M.D.

It might be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, big 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 contributes to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone like reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low functioning 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 problem, with only about 5 percent of those affected undergoing therapy.

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 ailments and male reproductive and sexual difficulties. He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see men since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a lesser amount of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.

The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.

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

Not exactly. There are quite a few medications that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it either, though surely if a person has less sex drive or less attention, it's more of a challenge to have a fantastic erection.

How can you determine 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 approaches is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. But no one quite agrees on a number. It's not like diabetes, where 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 recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment.

Is total testosterone the ideal point to be measuring? Or should we be measuring something else?

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

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

Endocrine Society recommendations summarized

This professional organization urges testosterone treatment for men who have both

Therapy is not Suggested for men who've

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • that a PSA greater 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 infections
  • class III or IV heart failure. find outfind out here

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

    For years, the recommendation was to receive a testosterone value early in the morning because levels start to drop after 10 or 11 a.m.. However, the information behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of this day. One reported no change in typical testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a modest sum, and probably not enough to affect diagnosis. Most guidelines still say it's important to perform the test in the morning, however for men 40 and above, it probably does not matter much, provided that they get their blood drawn before 5 or 6 p.m.

    There are some very interesting findings about dietary supplements. For instance, it appears that those that 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 make any recommendations that are clear.

    Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Based on the formula, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional 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 men had increased levels of testosterone; none reported any side effects throughout the year they had been followed.

    Since clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it is more capable of boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enhances -- sperm production. This makes medication like clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.

Formulations

What kinds of testosterone-replacement therapy are available? *

The earliest form is the injection, which we still use because it's cheap and since we faithfully get good testosterone levels in nearly everybody. The drawback is that a person should come in every few weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and return to research.

Topical therapies help maintain a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area on their skin. That limits its use.

The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. Based on my experience, it tends to be consumed to great levels in about 80% to 85 percent of guys, but leaves a substantial number who don't absorb enough for it to have a positive effect. [For specifics on various formulations, see table below.]

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

Men who start using the gels have to come back in to have their own testosterone levels measured again to be certain they're absorbing the right amount. Our goal is that 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 change for a month or two.

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