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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 guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it boosts the production of red blood cells, boosts mood, and aids cognition.

Over time, the "machinery" that makes testosterone gradually becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent a year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low working 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's an underdiagnosed problem, with just about 5 percent of those affected receiving treatment.

But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what risks 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 ailments and male sexual and reproductive problems. He's developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his patients, and he believes specialists should rethink the potential connection between testosterone-replacement treatment 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 guys because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should possess his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much smaller amount of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something which would usually be arousing.

The more of the symptoms you will find, the more probable it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by normalizing testosterone levels.

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

Not precisely. There are a number of medications that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go together with it either, though certainly if somebody has less sex drive or less attention, it is more of a challenge to have a good erection.

How do you determine whether or not a person is a candidate for testosterone-replacement therapy?

There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are some men who have low levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone for 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 few. It is not like diabetes, where if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should see here now and shouldn't receive testosterone therapy. For the original source a complete copy of these Read More Here instructions, log on to www.endo-society.org.

Is total testosterone the right thing to be measuring? Or should we be measuring something different?

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

The available part of total testosterone is called free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's only a little portion of this overall, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the correlation is greater than with total testosterone.

This professional organization recommends testosterone therapy for men who have both

  • Low levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy is not recommended for men who have

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

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

For years, the recommendation has been to get a testosterone value early in the morning because levels start to drop after 10 or 11 a.m.. But 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 mature 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 small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it's important to do the test in the morning, however for men 40 and over, it likely does not matter much, provided that they obtain their blood drawn before 5 or 6 p.m.

There are some very interesting findings about dietary supplements. By way of instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been studied thoroughly enough to make any clear recommendations.

In the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Based upon the formula, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, each one the guys had heightened levels of testosterone; none reported some side effects during the year they had been followed.

Since clomiphene citrate is not approved by the FDA for use in males, little information exists regarding the long-term effects of taking it (such as the risk of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone that want to father children.

What forms of testosterone-replacement treatment are available? *

The earliest form is an injection, which we 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 get a shot. A roller-coaster effect may also occur as blood glucose 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 large rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a red area in their skin. That limits its usage.

The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. The gel comes in tiny tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be consumed to good degrees in about 80% to 85 percent of men, but leaves a significant 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 downsides to using dyes? How long does it take for them to get the job done?

Men who begin using the gels have to return in to have their own testosterone levels measured again to make sure they are absorbing the right amount. Our goal 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 actually goes up quite quickly, in just several doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two.

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