Aspects For hrt - What's Required

A Harvard Specialist shares his Ideas on testosterone-replacement therapy

 

An interview with Abraham Morgentaler, M.D.

It might be said that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" which produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, starting 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 sex drive and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with just about 5 percent of those affected undergoing therapy.

But little consensus exists about 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 can stimulate prostate cancer.

He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and why he believes experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the average man to see a doctor?

As a urologist, I tend to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something which would usually be arousing.

The more of the symptoms you will find, the more probable it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.

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

Not exactly. There are a number of drugs which may reduce libido, such as the BPH medication 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 treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if a person has less sex drive or less attention, it is more of a challenge to get a fantastic erection.

How can you decide whether 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 those two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are a number of guys who have low levels of testosterone in their blood and have no symptoms.

Looking at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. However, no one really 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 apparent.

*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and webpage should not receive testosterone therapy. For a complete copy of these guidelines, log on to www.endo-society.org.

Is complete testosterone the right thing to be measuring? Or if we are measuring something else?

This is another area of confusion and great 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 body. However, about half of the testosterone that is circulating in the bloodstream isn't available to cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with testosterone.

Endocrine Society recommendations outlined

This professional organization recommends testosterone treatment for men who have both

Therapy is not Suggested for men who've

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

    Do time daily, diet, or other factors influence testosterone levels?

    For many years, the recommendation has been to get a testosterone value early in the morning since levels start to fall after 10 or even 11 a.m.. But the information behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of this day. One reported no change in typical testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably insufficient to affect diagnosis. Most guidelines still say it is important to perform the test in the morning, but for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

    There are a number of very interesting findings about diet. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been studied thoroughly enough to make any recommendations that are clear.

    Exogenous vs. endogenous testosterone

    Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based upon the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.

    At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six months, each one the guys had increased levels of testosteronenone reported any side effects during the year they were followed.

    Because clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.

    What kinds of testosterone-replacement treatment can be found? *

    The oldest form is an injection, which we still use since it is cheap and because we reliably get fantastic testosterone levels in almost everybody. The drawback is that a man needs to 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 research.

    Topical treatments help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a reddish area in their skin. That limits its use.

    The most widely used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. 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 has a tendency to be absorbed to good degrees in about 80% to 85% of men, but leaves a substantial number who do not consume enough for this to have a favorable effect. [For specifics on several different formulations, see table below.]

    Are there any drawbacks to using dyes? How long does it take for them to get the job done?

    Men who start using the gels have to return in to have their testosterone levels measured again to make certain they're absorbing the proper quantity. Our target is that the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, within several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.

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