A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It might be said that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and facial and body 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. It also fosters the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the testicular"machinery" which produces testosterone gradually becomes less effective, and testosterone levels start to drop, by approximately 1 percent per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like reduced libido 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" significance low working and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with just about 5 percent of those affected undergoing therapy.
He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own patients, and he believes experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average person to see a doctor?
As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.
The more of the symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs that may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. But a decrease in orgasm intensity usually does not go together with treatment for BPH. Erectile dysfunction does not usually go together with it , though surely if a person has less sex drive or less interest, it is more of a struggle to have a good erection.
How can you decide if a person is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether someone has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is over 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 recommendations for who should and should not receive testosterone treatment. see this For a complete copy of the instructions, log on to www.endo-society.org. Is complete testosterone the right thing to be measuring? Or should we be measuring something else? Well, this is just another area of confusion and good discussion, but I don't think that it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. However, about half of the testosterone that's circulating in the bloodstream is not available to cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Nearly every lab has a blood test to measure free testosterone. Though it's just a small fraction of this overall, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the significance is greater than with total testosterone.
What forms of testosterone-replacement therapy are available? * The earliest form is an injection, which we use since it is inexpensive and because we reliably become good testosterone levels in almost everybody. The disadvantage is that a person should come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to research. [See"Exogenous vs. endogenous testosterone," above.] Topical therapies help preserve a more uniform amount of blood testosterone. The first kind of topical treatment was a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a red area on their skin. That limits its use. The most widely used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. Based on my experience, it tends to be consumed to good degrees in about 80% to 85% of guys, but leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For specifics on various formulations, see table below.] Are there any drawbacks to using gels? How much time does it require them to get the job done? Men who start using the implants need to return in to have their own testosterone levels measured again to be sure they are absorbing the proper amount. Our target is the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, in just a few doses. I normally measure it after two weeks, although symptoms may not alter for a month or two. |