Core Aspects In testosterone therapy Around The Usa

A Harvard Specialist shares his Ideas on testosterone-replacement Treatment

A meeting with Abraham Morgentaler, M.D.

It might be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from women. It stimulates the development 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 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 might begin to have signs and symptoms of low testosterone like reduced sex drive and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5% of these affected undergoing therapy.

Studies have revealed that testosterone-replacement therapy may provide a wide selection of benefits for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 diseases and male reproductive and sexual difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and he thinks experts should reconsider the possible 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 have a tendency to see men since they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser quantity of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something that would normally be arousing.

The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.

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

Not exactly. There are quite a few medications which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it either, though surely if a person has less sex drive or less attention, it's more of a challenge to get a good erection.

How can you decide if or not a person is a candidate for testosterone-replacement therapy?

There are 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 approaches is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* considers 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, 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.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should pop over to these guys and shouldn't additional hints receive testosterone therapy.

Is total testosterone the ideal point to be measuring? Or if we are measuring something different?

This is another area of confusion and great discussion, but I don't think 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 human body. But about half of the testosterone that's circulating in the bloodstream isn't readily available to cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available part of total testosterone is known as free testosterone, and it is readily available to cells. Though it's only a small portion of this overall, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater than with total testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have

Therapy Isn't recommended for men who have

  • Prostate or breast cancer
  • a nodule on the prostate which may be felt during a DRE
  • a PSA greater than 3 ng/ml without additional 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 factors 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 demonstrated little change in blood testosterone levels in men 40 and mature over the course of the 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 small amount, and probably not enough to affect identification. Most guidelines still say it is important to do the evaluation in the morning, but for men 40 and over, it probably doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

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

    Within this guide, testosterone-replacement therapy 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 enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with 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, each one the guys had heightened levels of testosteronenone reported any side effects throughout the year they were followed.

    Since clomiphene citrate is not approved by the FDA for use in males, little information exists about the long-term effects of carrying it (such as the risk of developing prostate cancer) or if it's more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes drugs such as clomiphene citrate one of just a few options for men with low testosterone who want to father children.

    What kinds of testosterone-replacement treatment are available? *

    The oldest form is an injection, which we still use since it is cheap and because we reliably get fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to baseline.

    Topical treatments help preserve a more uniform amount of blood testosterone. The first form of topical therapy was a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area on their skin. That limits its use.

    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. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb enough for it to have a positive effect. [For specifics on various formulations, see table below.]

    Are there any drawbacks to using dyes? How much time does it require them to get the job done?

    Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper amount. Our target is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, though symptoms may not alter for a month or two.

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