A Harvard Specialist shares his thoughts on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
As time passes, the testicular"machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms 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 USA. Yet it's an underdiagnosed problem, with only about 5 percent of these affected receiving treatment.
Studies have revealed that testosterone-replacement therapy can offer a wide selection of advantages for men with hypogonadism, including improved 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.
Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate ailments and male sexual and reproductive problems. He's developed specific experience 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 thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average man to see a physician?
As a urologist, I have a tendency 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 any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid out of 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, however, they're often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications that may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less attention, it is more of a struggle to get a good erection.
How do you decide if a man is a candidate for testosterone-replacement therapy?
There are just 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 highest testosterone possess the least. However, there are some men who have reduced levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone for a total testosterone level of less than 300 ng/dl, and I think that is a sensible guide. However, no one quite agrees on a number. It is similar to diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. web Is total testosterone the ideal point to be measuring? Or should we be measuring something else? This is another area of confusion and great discussion, but I don't think that it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the body. However, about half of the testosterone that's circulating in the blood is not readily available to the 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 called free testosterone, and it is readily available to the cells. Even though it's just a small portion of the overall, the free testosterone level is a pretty good indicator of low testosterone. It is not perfect, but the correlation is greater compared to total testosterone.
Do time daily, diet, or other factors influence testosterone levels? For years, the recommendation was to get a testosterone value early in the morning since levels begin to drop after 10 or even 11 a.m.. But the information 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 p.m. Between 6 and 2 p.m., it went down by 13%, a small sum, and probably not enough to affect identification. Most guidelines still say it is important to do the test in the morning, however for men 40 and above, 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 dietary supplements. By way of example, it appears that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear.
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