A Harvard Specialist shares his Ideas on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with only about 5% of those affected undergoing therapy.
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 ailments and male sexual and reproductive problems. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and why he believes specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the typical person to see a doctor?
As a urologist, I have a tendency to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser quantity of fluid out of 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 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, however, they are often treatable and reversible by decreasing testosterone levels.
Are not those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs that may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity usually doesn't go along with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less attention, it is more of a struggle to get a good erection.
How can you determine if or not a person is a candidate for testosterone-replacement therapy?
There are just two ways that we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are some men who have low levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. However, no one really agrees on a number. It is similar to 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 apparent.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not try this web-site receive testosterone therapy. For a complete copy of these guidelines, log on to www.endo-society.org. |
Is complete testosterone the right thing 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 physicians learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the human body. But about half of their testosterone that's circulating in the bloodstream isn't available to cells.
The available part of overall testosterone is called 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 portion of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater compared to total testosterone.
This professional organization recommends testosterone treatment for men who have both
- Reduced levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not Suggested for men who have
- Breast or prostate cancer
- a nodule on the prostate that can be felt during a DRE
- that a PSA greater than 3 ng/ml without additional evaluation
- a hematocrit greater than 50 percent 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 was to get a testosterone value early in the morning since levels begin to drop after 10 or even 11 a.m.. However, the data behind that recommendation were attracted to 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 typical testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it is important to do the evaluation in the morning, however for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about diet. By way of instance, it seems that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been researched thoroughly enough to make any recommendations that are clear.
Exogenous vs. endogenous testosterone
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Depending on the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.
Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the creation of natural testosterone, termed nitric oxide, in men. Within four to six months, each one the guys had increased levels of testosteronenone reported any side effects during the year they were followed.
Because clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.
What kinds of testosterone-replacement treatment are available? *
The oldest form is an injection, which we use since it's inexpensive and because we reliably become fantastic testosterone levels in almost everybody. The disadvantage is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to research. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical treatments help preserve a more uniform level of blood testosterone. The first form of topical treatment 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 red area in their skin. That restricts its use.
The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off with -- is a topical gel. According to my experience, it has a tendency to be absorbed to good degrees in about 80% to 85% of men, but leaves a substantial number who do not consume enough for this to have a favorable effect. [For specifics on several different formulations, see table below.]
Are there any drawbacks to using dyes? How long does it take for them to get the job done?
Men who start using the gels have to return in to have their testosterone levels measured again to make certain they're absorbing the proper amount. Our target is that the mid to upper range of normal, which generally means approximately 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, even though symptoms may not alter for a month or two.