An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" which makes testosterone slowly becomes less effective, and testosterone levels start to fall, by approximately 1% per year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced sex drive and sense of energy, 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 functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, with just about 5 percent of these affected undergoing therapy.
Much of the current debate focuses on the long-held belief that testosterone can stimulate prostate cancer.
He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his own patients, and he believes experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.Symptoms and diagnosis
What symptoms and signs of low testosterone prompt the typical person to see a doctor?
As a urologist, I tend to observe men because they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a much lesser amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something which would usually be arousing.
The more of these symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to dismiss these"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 quite a few drugs that may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity usually does not go along with treatment for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less attention, it's more of a struggle to have a good erection.
How can you decide whether a man is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, 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 possess the least. But there are a number of guys who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a few. It's similar to diabetes, in which if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
|*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone have a peek at this website therapy. Watch"Endocrine Society recommendations summarized." For a complete copy of the instructions, log on visit this web-site to www.endo-society.org.|
Is complete testosterone the right point to be measuring? Or should we be measuring something else?
Well, this is just another area of confusion and good discussion, but I do not think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the human body. However, about half of the testosterone that's circulating in the blood isn't readily available to the cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Though it's only a small portion of this total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not ideal, but the correlation is greater than with testosterone.
Endocrine Society recommendations outlined
This professional organization recommends testosterone treatment for men who have
Therapy is not Suggested for men who've
Do time of day, diet, or other elements influence testosterone levels?
For many years, the recommendation has been to get a testosterone value early in the morning because levels start to drop after 10 or even 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 older within the course of this day. One reported no change in average testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a modest amount, and probably not enough to influence identification. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and above, it likely doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about dietary supplements. For instance, it seems that individuals that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been studied thoroughly enough to create any recommendations that are clear.
In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Based upon the formulation, 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.
Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, also known as nitric oxide, in men. 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 of the men had increased levels of testosteronenone reported any side effects during the year they had been followed.
Since 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 effective at boosting testosterone than exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enhances -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone that want to father children.Formulations
What forms of testosterone-replacement treatment are available? *
The earliest form is the injection, which we use since it's inexpensive and because we faithfully get good testosterone levels in nearly everybody. The disadvantage is that a person should come in every few weeks to find a shot. A roller-coaster effect may also happen as blood testosterone levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical treatments help preserve a more uniform amount of blood glucose. The first form of topical therapy was a patch, but it has a very high rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a red area in their skin. That restricts its usage.
The most commonly used testosterone preparation in the United States -- and the one I start almost everyone off -- is a topical gel. According to my experience, it has a tendency to be consumed to great levels in about 80% to 85 percent of men, but that leaves a substantial number who do not consume sufficient for it to have a positive effect. [For details on various formulations, see table ]
Are there any downsides to using dyes? How much time does it take for them to get the job done?
Men who begin using the implants need to return in to have their testosterone levels measured again to make certain they're absorbing the right 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 really goes up quite quickly, within several doses. I usually measure it after 2 weeks, though symptoms may not alter for a month or two.