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