Rudimentary Aspects Of testosterone therapy Considered

A Harvard expert shares his thoughts on testosterone-replacement Treatment

An interview 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, large muscles, and facial and body hair, distinguishing them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it boosts the creation of red blood cells, boosts mood, and aids cognition.

As time passes, the "machinery" which makes testosterone gradually becomes less effective, and testosterone levels begin to drop, by approximately 1 percent a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone like reduced libido and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5% of these affected undergoing therapy.

But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.

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 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 main hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.

The more of the symptoms there are, the more probable 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 normalizing testosterone levels.

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

Not precisely. There are a number of medications that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no wonder. 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 certainly if a person has less sex drive or less interest, it is more of a challenge to get a fantastic erection.

How can you determine if a person is a candidate for testosterone-replacement treatment?

There are two ways we determine whether someone has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two approaches is far from perfect. Normally men 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 signs.

Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. For a complete copy of the see thischeck this guidelines, log on to www.endo-society.org.

Is total testosterone the ideal point to be measuring? Or should we be measuring something else?

This is just another area of confusion and good debate, but I do not think that it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream isn't readily available to the cells.

The available part of total testosterone is known as free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's just a little portion of this overall, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the correlation is greater compared to testosterone.

This professional organization recommends testosterone treatment for men who have both

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

Therapy Isn't Suggested for men who've

  • Breast or prostate cancer
  • a nodule on the prostate which may be felt during a DRE
  • that a PSA higher than 3 ng/ml without additional analysis
  • that a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV content heart failure.

    Do time of day, diet, or other factors affect testosterone levels?

    For years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, 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 within the course of this day. One reported no change in typical testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest amount, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to perform the evaluation in the morning, but for men 40 and above, it likely does not matter much, provided that they get their blood drawn before 5 or 6 p.m.

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

    Exogenous vs. endogenous testosterone

    Within the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is 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, can boost the creation of natural testosterone, termed nitric oxide, in men. 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 of the guys had heightened levels of testosteronenone reported any side effects throughout the year they had been followed.

    Since clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly 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.

    Formulations

    What forms of testosterone-replacement treatment are available? *

    The earliest 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 should come in every few weeks to get a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to research.

    Topical treatments help preserve a more uniform level of blood glucose. The first form of topical therapy has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a red area on their skin. That restricts its use.

    The most widely used testosterone preparation in the United States -- and also the one I begin almost everyone off with -- 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 various formulations, see table ]

    Are there any downsides to using gels? How much time does it require them to work?

    Men who start using the implants need to return in to have their testosterone levels measured again to be sure they're absorbing the proper quantity. Our goal is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, within a few doses. I usually measure it after 2 weeks, even though symptoms may not change for a month or two.

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