Vital Factors In trt Described

A Harvard expert shares his thoughts on testosterone-replacement therapy

An interview with Abraham Morgentaler, M.D.

It might be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, big 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.

As time passes, the "machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to drop, by about 1 percent per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have symptoms and signs 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 problem, with just about 5 percent of those affected undergoing therapy.

Studies have revealed that testosterone-replacement therapy may provide a wide range of advantages for men with hypogonadism, including enhanced 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 can stimulate prostate cancer.

He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his 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 person to see a physician?

As a urologist, I tend to see guys because they have sexual complaints. The main 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 possess his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a lesser amount of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something which would usually be arousing.

The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.

Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are quite a few medications that may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if somebody has less sex drive or less attention, it's more of a challenge to get a good erection.

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

There are two ways we determine whether somebody has low 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 ideal. Normally guys with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. However, there are some 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 to be a total testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one really agrees on a few. It is similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. For a my site complete copy of YOURURL.com these instructions, log on to www.endo-society.org.

Is total testosterone the right thing 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 total testosterone, or all the testosterone in the human body. But about half of the testosterone that's circulating in the bloodstream is not available to the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of total testosterone is known as free testosterone, and it is readily available to cells. Though it's just a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It's not perfect, but the significance is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone therapy for men who have both

Therapy Isn't Suggested for men who have

Prostate or breast cancer
a nodule on the prostate which can be felt during a DRE
a PSA higher than 3 ng/ml without additional evaluation
a hematocrit greater than 50 percent or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract infections

class 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 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of this day. One reported no change in typical testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably not enough to affect diagnosis. Most guidelines nevertheless say it's important to perform the test in the morning, however 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 a number of very interesting findings about dietary supplements. For instance, it appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to create any clear recommendations.

Exogenous vs. endogenous testosterone

Within this guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Based on the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.

Within four to six months, all the men had increased levels of testosterone; none reported any side effects throughout the entire year they were followed.

Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the risk of developing prostate cancer) or if it is more capable of boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication like clomiphene citrate one of only a few options for men with low testosterone who want to father children.

What kinds of testosterone-replacement treatment are available? *

The oldest form is an injection, which we still use because it is inexpensive and since we faithfully become good testosterone levels in nearly everybody. The disadvantage is that a man should come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and then return to baseline.

Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical treatment has been a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area on their skin. That restricts its usage.

The most widely used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb enough for this to have a positive impact. [For details on several different formulations, see table ]

Are there any downsides 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 make sure they are absorbing the proper quantity. Our goal is the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, in just several doses. I normally measure it after 2 weeks, though symptoms may not change for a month or two.

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