Aspects For trt - What's Required

A Harvard expert shares his Ideas on testosterone-replacement Treatment

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 facial and body hair, differentiating them from women. It stimulates the development 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 makes testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed issue, with just about 5 percent of those affected undergoing therapy.

But little consensus exists on 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.

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 difficulties. 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 utilizes his patients, and why he thinks experts should reconsider the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt that the typical person to see a doctor?

As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.

The more of these symptoms there are, the more likely 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.

Are not those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications which may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not usually go along with it , 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 whether a man is a candidate for testosterone-replacement therapy?

There are two ways 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 ideal. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are some guys who have reduced levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a few. It is not like diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. For a complete copy of the look at this web-site guidelines, log on to www.endo-society.org.

Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?

Well, this is just 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 overall 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 is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available portion of total testosterone is known as free testosterone, and it's readily available to cells. Though it's only a little portion of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater compared to total testosterone.

Endocrine Society recommendations outlined

This professional organization recommends testosterone treatment for men who have both

Therapy is not Suggested for men who've

  • Prostate or breast cancer
  • a nodule on the prostate which can be felt during a DRE
  • that a PSA greater than 3 ng/ml without further analysis
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure.

    Do time daily, diet, or other elements affect testosterone levels?

    For many years, the recommendation was to receive a testosterone value early in the morning because levels begin to fall after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature within the course of the day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it is important to do the test in the morning, however for men 40 and over, it likely doesn't matter much, as long as they obtain their blood drawn before 6 or 5 p.m.

    There are some very interesting findings about diet. By way of instance, it seems that individuals who 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 make any recommendations that are clear.

    Exogenous vs. endogenous testosterone

    Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based upon the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.

    Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the creation of natural testosterone, also termed endogenous testosterone, in men. Within four to six months, all of the guys had increased levels of testosteronenone reported any side effects during the year they were followed.

    Because clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.

    What forms of testosterone-replacement therapy are available? *

    The oldest form is an injection, which we use since it's inexpensive and because we reliably become fantastic testosterone levels in almost everybody. The disadvantage is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also occur as blood glucose levels peak and return to baseline. [See"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help preserve a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a very high 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 widely used testosterone preparation in the United States -- and the one I start almost everyone off -- is a topical gel. The gel comes in miniature tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be consumed to great levels in about 80% to 85% of guys, but leaves a substantial number who do not absorb enough for this to have a favorable effect. [For specifics on several different formulations, see table below.]

    Are there any drawbacks to using dyes? How much time does it require them to get the job done?

    Men who begin using the gels have to return in to have their own testosterone levels measured again to make certain they're absorbing the proper amount. Our goal is the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, in just a few doses. I normally measure it after two weeks, even though symptoms may not change for a month or two.

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