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A Harvard Specialist shares his thoughts on testosterone-replacement therapy

It might be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1 percent a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone such as reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs 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 is an underdiagnosed issue, with just about 5% of these affected undergoing therapy.

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 person to see a physician?

As a urologist, I tend to observe guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser amount 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 decreasing testosterone levels.

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

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

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

There are two ways that we determine whether someone has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between these two approaches is far from ideal. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no signs.

Looking at the biochemical amounts, 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 few. It is similar to diabetes, in which if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment.

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

Well, this is another area of confusion and great debate, but I do not think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. But about half of the testosterone that's circulating in the bloodstream is not available to cells.

The available part of overall testosterone is known as free testosterone, and it is readily available to cells. Almost every laboratory has a blood test to measure free testosterone. Though it's just a small fraction 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.

This professional organization urges testosterone treatment for men who have both

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

Therapy is not Suggested for men who have

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • that a PSA greater 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 visit the websitevisit this website 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 information behind that recommendation were drawn from healthy young men. Two recent studies demonstrated 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 6 and 2 p.m., it went down by 13%, a small sum, and probably not enough to affect diagnosis. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and over, it probably does not 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. 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 has not been studied thoroughly enough to create any clear recommendations.

    In the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending upon the formula, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.

    Within four to six months, all of the guys had heightened levels of testosterone; none reported some side effects throughout 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 carrying it (such as the risk of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enriches -- sperm production. This makes drugs like clomiphene citrate one of just a few options for men with low testosterone that want to father children.

    What forms of testosterone-replacement treatment can be found? *

    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 can also happen as blood glucose levels peak and return to research.

    Topical treatments help maintain a more uniform level of blood testosterone. The first form of topical therapy has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a reddish area in their skin. That restricts its usage.

    The most widely used testosterone preparation from the United States -- and also the one I begin almost everyone off with -- is a topical gel. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be consumed to great degrees in about 80% to 85 percent of guys, 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 gels? 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 right quantity. Our goal 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 a few doses. I normally measure it after 2 weeks, even although symptoms may not change for a month or two.

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