A Harvard Specialist shares his Ideas on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" that makes testosterone slowly becomes less effective, and testosterone levels start to fall, by approximately 1% per year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with only about 5% of these affected receiving treatment.
Studies have revealed that testosterone-replacement therapy can provide a wide range of advantages for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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.
He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own patients, and why 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 find a physician?
As a urologist, I have a tendency to observe men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men may experience other symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid out of 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 there are, the more probable it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.
Aren't those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs which may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to get a good erection.
How do you decide if or not a man is a candidate for testosterone-replacement treatment?
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 symptoms and signs, and the correlation between these two approaches is far from perfect. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are a number of guys who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one really agrees on a number. It's not like diabetes, where if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. |
Is complete testosterone the right point to be measuring? Or if we are measuring something else?
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 learned about overall testosterone, or all of the testosterone in the body. However, about half of their testosterone that's circulating in the blood is not readily available to cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
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 little portion of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater compared to testosterone.
This professional organization recommends testosterone treatment for men who have
Therapy Isn't recommended for men who've
- Prostate or breast cancer
- a nodule on the prostate that may be felt during a DRE
- a PSA higher than 3 ng/ml without further analysis
- a hematocrit greater than 50 percent or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III or IV go to my sitepop over here heart failure. resource
Do time daily, diet, or other elements influence testosterone levels?
For many years, the recommendation has been to get a testosterone value early in the morning because levels start to fall after 10 or 11 a.m.. But the information behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of this day. One reported no change in average testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a small amount, and probably insufficient to affect diagnosis. Most guidelines nevertheless say it is important to perform the evaluation in the morning, however for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about diet. For instance, it appears that those who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to make any recommendations that are clear.
In this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Depending on the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.
Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, termed endogenous testosterone, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all of the men had heightened levels of testosterone; none reported any side effects during the entire year they were 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 (including the probability of developing prostate cancer) or if it's more capable of boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.
FormulationsWhat forms of testosterone-replacement therapy can be found? *
The earliest form is the injection, which we still use because it is inexpensive and because we reliably get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and return to baseline.
Topical therapies help maintain a more uniform amount of blood testosterone. The first form of topical treatment was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area in 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 -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes from miniature tubes or in a special 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 leaves a substantial number who don't absorb sufficient for this to have a favorable effect. [For details on several different formulations, see table below.]
Are there any drawbacks to using gels? How long does it take for them to work?
Men who start using the implants need to return in to have their testosterone levels measured again to be sure they are absorbing the proper amount. Our target 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 quickly, within a few doses. I usually measure it after two weeks, though symptoms may not change for a month or two.