Clarifying Vital Elements For testosterone therapy

A Harvard expert shares his Ideas on testosterone-replacement Treatment

 

 

It might be said that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the production of red blood cells, boosts mood, and aids cognition.

As time passes, the testicular"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 into 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's an underdiagnosed issue, with just about 5% of these affected receiving treatment.

But little consensus exists on 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 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 sexual and reproductive difficulties. He has developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his own patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see men because they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a lesser amount of fluid out of ejaculation, and a sense of numbness in the penis 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 dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by decreasing testosterone levels.

Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if somebody has less sex drive or less attention, it is more of a struggle to have a fantastic erection.

How do you determine whether a man is a candidate for testosterone-replacement treatment?

There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are some guys who have reduced levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a few. It is not like diabetes, in which if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations pop over to these guys for who should and shouldn't receive testosterone treatment.

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

This is just another area of confusion and great discussion, but I don't think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they learned about total 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. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available portion of total testosterone is called free testosterone, and it's readily available to cells. Even though it's just a little portion of the overall, the free testosterone level is a pretty good indicator of low testosterone. It is not perfect, but the correlation is greater compared to total testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone therapy for men who have

Therapy is not Suggested for men who've

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

Do time daily, diet, or other elements affect testosterone levels?

For many years, the recommendation has been to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. However, the data behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably not enough to affect identification. Most guidelines nevertheless say it's important to perform the test in the morning, but for men 40 and above, it likely doesn't matter much, provided that they get their blood drawn before 6 or 5 p.m.

There are a number of very interesting findings about dietary supplements. For instance, it appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.

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

In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, all of the men had heightened levels of testosterone; none reported any side effects during the year they had been followed.

Since clomiphene citrate isn't 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 compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enhances -- sperm production. That makes medication such as clomiphene citrate one of only a few options for men with low testosterone that wish to father children.

Formulations

What kinds of testosterone-replacement treatment are available? *

The earliest form is the injection, which we use since it is inexpensive and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a person should come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to research.

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

The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off with -- is a topical gel. The gel comes from tiny tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be absorbed to great levels in about 80% to 85% of guys, but that leaves a substantial number who do not absorb enough for this to have a positive effect. [For details on various formulations, see table below.]

Are there any downsides to using dyes? How long does it require them to work?

Men who begin using the implants need to come back in to have their testosterone levels measured again to be sure they are absorbing the proper amount. Our target is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, in just several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.

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