Examining testosterone therapy Systems

A Harvard Specialist shares his Ideas on testosterone-replacement therapy

 

 

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 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 production 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, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of these affected receiving treatment.

Various studies have shown that testosterone-replacement therapy can offer a vast selection of benefits for men with hypogonadism, such as improved 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 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 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 specialists should rethink 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 tend to observe guys because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should 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, however, they are often treatable and reversible by normalizing testosterone levels.

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

Not precisely. There are a number of drugs which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no question. But a decrease in orgasm intensity usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if a person has less sex drive or less attention, it is more of a challenge to get a good erection.

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

There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess 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 for a entire testosterone level of less than 300 ng/dl, and I believe that is a sensible 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 and shouldn't receive testosterone therapy. visit homepage

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

This is just another area of confusion and good 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. However, about half of the testosterone that's circulating in the bloodstream isn't readily available to cells. It's closely 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 is readily available to the cells. Even 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 perfect, but the correlation is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone treatment for men who have both

Therapy is not Suggested for men who've

  • 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
  • that a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class Read Full Report 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 Between 6 and 2 p.m., it went down by 13 percent, a small amount, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it's important to perform the test in the morning, however for men 40 and above, it probably does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

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

    In the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending upon the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional 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 months, all the men had increased levels of testosterone; none reported some side effects throughout the year they had been followed.

    Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of carrying it (including the risk of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. This makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.

    What forms of testosterone-replacement treatment are available? *

    The earliest form is an injection, which we use since it is cheap and because we reliably become fantastic testosterone levels in almost everybody. The disadvantage is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and then return to research.

    Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In one study, as many as 40 percent of people that 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. The gel comes in miniature tubes or in a special 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 guys, but 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 long does it take for them to work?

    Men who start using the gels have to come back in to have their testosterone levels measured again to be certain they are absorbing the proper 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 the blood actually goes up quite quickly, within a few doses. I normally measure it after 2 weeks, even although symptoms may not alter for a month or two.

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