Effective Secrets For testosterone therapy - The Inside Track

A Harvard expert shares his thoughts on testosterone-replacement therapy

 

 

It could be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, 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 assists cognition.

As time passes, the testicular"machinery" that makes testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent per year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as 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 USA. Yet it's an underdiagnosed issue, with just about 5% of those affected undergoing therapy.

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 problems. He's 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 he thinks experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt the typical man to see a physician?

As a urologist, I tend to observe men since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and any man 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 smaller quantity of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally be arousing.

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

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

Not precisely. There are quite a few drugs which may reduce libido, such as 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 therapy for BPH. Erectile dysfunction does not usually go along with it either, though surely if a person has less sex drive or less interest, it's more of a struggle to have a fantastic erection.

How do you determine if 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 symptoms and signs, and the correlation between those two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys 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 purely at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total 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's 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.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations this link for who should and should not receive testosterone useful source treatment.

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

Well, this is another area of confusion and good discussion, but I do not think 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 of the testosterone in the human body. However, about half of their testosterone that is circulating in the blood is not available to the 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 known as free testosterone, and it's readily available to the cells. Though it's just a little fraction of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone treatment for men who have

Therapy Isn't Suggested for men who've

  • Breast or prostate cancer
  • a nodule on the prostate which can be felt during a DRE
  • a PSA higher than 3 ng/ml without further evaluation
  • 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 of day, diet, or other elements affect testosterone levels?

    For years, the recommendation was to get a testosterone value early in the morning because levels begin to drop after 10 or even 11 a.m.. However, the data behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older over the course of this day. One reported no change in average testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably not enough to influence diagnosis. Most guidelines nevertheless say it is important to do the evaluation in the morning, but for men 40 and above, it likely does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.

    There are a number of rather interesting findings about dietary supplements. By way of instance, it appears that individuals that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to make any recommendations that are clear.

    Exogenous vs. endogenous testosterone

    In this article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Based on the formula, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.

    Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, termed endogenous testosterone, in men. Within four to six weeks, each one the men had increased levels of testosteronenone reported any side effects throughout the entire year they had been followed.

    Since clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (including the risk of developing prostate cancer) or if it's more effective at boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.

    What kinds of testosterone-replacement treatment are available? *

    The oldest form is an injection, which we use because it is cheap and since we reliably get good testosterone levels in almost everybody. The drawback is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to baseline. [See"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help preserve a more uniform amount of blood glucose. The first form of topical treatment has been a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a reddish area in their skin. That restricts its usage.

    The most commonly used testosterone preparation in the United States -- and the one I start almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but leaves a substantial number who don't absorb sufficient for it to have a favorable impact. [For details on several different 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 make sure they're absorbing the right amount. Our target is that the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within several doses. I normally measure it after 2 weeks, even though symptoms may not change for a month or two.

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