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 diagnosisWhat 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
Therapy is not Suggested for men who have
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