An interview with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to drop, by approximately 1% per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone like reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.
Much of the current debate focuses on the long-held belief that testosterone can stimulate prostate cancer.
He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his patients, and why he believes specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.Symptoms and diagnosis
What symptoms and signs of low testosterone prompt the average person to find a physician?
As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid from ejaculation, and a sense 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.
Are not 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 which may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though surely if somebody has less sex drive or less attention, 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 just two ways that we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between these two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. However, there are some guys who have low levels of testosterone in their blood and have no symptoms.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one quite agrees on a few. It is similar to 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.
|*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and look at these guys shouldn't receive testosterone therapy. For browse around these guys a complete copy of the instructions, log my latest blog post on to www.endo-society.org.|
Is total testosterone the ideal point to be measuring? Or should we be measuring something different?
This is another area of confusion and good discussion, but I don't think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the body. But about half of the testosterone that is circulating in the bloodstream is not readily available to cells.
The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Almost every laboratory has a blood test to measure free testosterone. Though it's just a little fraction of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the correlation is greater than with testosterone.
Endocrine Society recommendations outlined
This professional organization urges testosterone treatment for men who have
Therapy Isn't Suggested for men who've
Do time daily, diet, or other elements affect testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning because levels start to fall after 10 or 11 a.m.. However, the information behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of this day. One reported no change in average testosterone until after 2 Between 6 and 2 p.m., it went down by 13%, a small amount, and probably not enough to influence identification. Most guidelines nevertheless say it's important to do the test in the morning, but for men 40 and over, 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 instance, it appears that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been researched thoroughly enough to make any clear recommendations.
Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending upon 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 weeks, each one of the men had increased levels of testosterone; none reported any side effects during the entire year they had been followed.
Because clomiphene citrate isn't 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's more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.
What forms of testosterone-replacement treatment are available? *
The oldest form is the injection, which we still use since it is inexpensive and since we reliably get good testosterone levels in nearly everybody. The disadvantage is that a person 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 baseline. [See"Exogenous vs. endogenous testosterone," above.]
Topical treatments help maintain a more uniform amount of blood testosterone. The first kind 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 people that used the patch developed a red area on their skin. That limits its usage.
The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. According to my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of guys, but leaves a significant number who don't consume enough for it to have a favorable effect. [For details on several different formulations, see table below.]
Are there any downsides to using gels? How long does it require them to work?
Men who begin using the gels have to return in to have their testosterone levels measured again to make certain they're absorbing the right quantity. Our target is the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I normally measure it after 2 weeks, although symptoms may not alter for a month or two.