A meeting with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial 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. Additionally, it 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, starting in the 40s. As guys get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning 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 problem, with only about 5 percent of these affected undergoing therapy.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 sexual and reproductive difficulties. He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he thinks experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.Symptoms and diagnosis
What signs and symptoms of low testosterone prompt that the typical man to see a physician?
As a urologist, I have a tendency to see guys since they have sexual complaints. The primary hallmark of low testosterone is reduced 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 can experience other symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a 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 the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they are 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 that may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go along with it , though surely if somebody has less sex drive or less interest, it's more of a struggle to get a fantastic erection.
How do you decide whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Normally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are a number of 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 entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. But no one really agrees on a few. 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 is not quite as apparent.
|*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should see this site and should not receive testosterone therapy. For a complete copy of check my blog these guidelines, visit the site log on to www.endo-society.org.
Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?
This is another area of confusion and good discussion, but I don't think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the human body. But about half of the testosterone that is circulating in the blood is not 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 portion of overall testosterone is known as free testosterone, and it's readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Though it's only a small portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the correlation is greater compared to testosterone.
This professional organization urges testosterone treatment for men who have both
Therapy Isn't Suggested for men who have
Do time daily, diet, or other elements influence testosterone levels?
For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to drop after 10 or 11 a.m.. But the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to perform the evaluation in the morning, however for men 40 and above, 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 example, it appears that those that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.
Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based on the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects.
Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, known as endogenous testosterone, in men. Within four to six months, all the men had increased levels of testosteronenone reported some side effects during the entire year they had been followed.
Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the risk of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children.
What kinds of testosterone-replacement therapy can be found? *
The oldest form is an injection, which we use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a man needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to research.
Topical therapies 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 reddish area on their skin. That restricts its use.
The most commonly used testosterone preparation from the United States -- and the one I begin almost everyone off -- is a topical gel. The gel comes from tiny tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be absorbed to good degrees in about 80% to 85% of guys, but that leaves a significant number who do not consume sufficient for it to have a favorable effect. [For details on several different formulations, see table below.]
Are there any downsides to using gels? How much time does it require them to work?
Men who begin using the gels have to come back in to have their own testosterone levels measured again to make certain they are absorbing the right quantity. Our goal is the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within several doses. I normally measure it after 2 weeks, although symptoms may not alter for a month or two.