A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
It could be said that testosterone is what makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" which produces testosterone gradually becomes less effective, and testosterone levels begin to drop, by about 1 percent per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone such as reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low working 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's an underdiagnosed problem, with just about 5 percent of those affected receiving treatment.
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 may 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 reproductive and sexual difficulties. He has developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his patients, and he believes experts should reconsider the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average person to see a physician?
As a urologist, I tend to observe men since they have sexual complaints. The primary hallmark of reduced testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a lesser amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would usually be arousing.
The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not usually go together with it , though certainly if somebody has less sex drive or less interest, it is more of a struggle to have a good erection.
How do you determine whether or not a person is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. However, there are a number of guys who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. However, no one really agrees on a few. It is similar to diabetes, where if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. For a complete copy find out this here of the guidelines, log find out this here on to www.endo-society.org. Is total testosterone the right thing to be measuring? Or should we be measuring something different? This is just another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't readily available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The available part of total testosterone is called free testosterone, and it's readily available to the cells. Almost every lab has a blood test to measure free testosterone. Even though it's only a little portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater compared to total testosterone. This professional organization recommends testosterone therapy for men who have both
Therapy Isn't Suggested for men who have
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