A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like lower libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low working and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed issue, with only about 5% of those affected receiving treatment.
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 sexual and reproductive difficulties. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and why he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.Symptoms and diagnosis
What symptoms and signs of low testosterone prompt that the average man to find a doctor?
As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a feeling 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 probable it is that a man has low testosterone. Many physicians tend to dismiss those"soft symptoms" as a normal part of aging, but they're 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 exactly. There are quite a few drugs which may reduce libido, including 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 doesn't go along with therapy for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How can you determine if a person is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between these two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are some men who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. But no one really agrees on a number. It's similar to diabetes, where if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
|*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. read this article Watch"Endocrine visit our website Society recommendations summarized." For a complete check over here copy of the guidelines, log on to www.endo-society.org.
Is total testosterone the ideal point to be measuring? Or should we be measuring something else?
Well, this is just another area of confusion and great discussion, but I don't think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the human body. But about half of their testosterone that is circulating in the bloodstream is not readily available to the cells. It's 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 called free testosterone, and it's readily available to the cells. Though it's just a small portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the correlation is greater compared to total testosterone.
Do time daily, diet, or other factors influence testosterone levels?
For many years, the recommendation was to get a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. But the data behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within the course of this day. One reported no change in typical testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to affect identification. Most guidelines still say it's important to do the test in the morning, however for men 40 and over, it likely doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m.
There are some very interesting findings about diet. For instance, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear.
What kinds of testosterone-replacement therapy can be found? *
The earliest form is the injection, which we still use since it's cheap and because we reliably get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to research.
Topical treatments help preserve a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a red area in their skin. That limits its usage.
The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes in tiny tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be consumed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb sufficient for this to have a positive effect. [For details on several different formulations, see table below.]
Are there any downsides to using dyes? How long does it require them to get the job done?
Men who start using the gels have to return in to have their own testosterone levels measured again to make certain they are absorbing the proper amount. Our target is that the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within a few doses. I normally measure it after 2 weeks, though symptoms may not alter for a month or two.