The Options For Vital Criteria In trt

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

 

A meeting 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 , 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 "machinery" that produces testosterone slowly becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as lower sex drive and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. 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 USA. Yet it is an underdiagnosed problem, with only 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 diseases and male reproductive and sexual problems. He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and why he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt that the typical man 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 may be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty 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 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 normalizing testosterone levels.

Aren't 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 drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally does not go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.

How can 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 approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are a number of 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 total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one really 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 isn't quite as apparent.

*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. For a complete link copy of the guidelines, log on to www.endo-society.org.

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

Well, this is just another area of confusion and great discussion, but I do not think it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they heard about total 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 overall testosterone is known as free testosterone, and it's readily available to cells. Even though it's just a small 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

  • Reduced levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy Isn't Suggested for men who have

  • Breast or prostate cancer
  • a nodule on the prostate that may be felt during a DRE
  • a PSA higher than 3 ng/ml without further evaluation
  • that a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV heart failure.

Do time daily, diet, or other factors influence testosterone levels?

For many years, the recommendation has been to receive a testosterone value early in the morning because levels begin to drop after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older 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 small amount, and probably not enough to affect diagnosis. Most guidelines nevertheless say it is important to do the evaluation in the morning, but for men 40 and above, it likely does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

There are some rather interesting findings about diet. For instance, it appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to create any clear recommendations.

Exogenous vs. endogenous testosterone

In the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending on the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.

Within four to six months, each one the guys had increased levels of testosteronenone reported any side effects during the entire year they had been followed.

Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists regarding the long-term ramifications of carrying 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 enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.

What kinds of testosterone-replacement treatment are available? *

The oldest form is an injection, which we still use since it is cheap and since we reliably get good testosterone levels in almost everybody. The drawback is that a person needs to come in every few weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical treatments help preserve a more uniform amount of blood testosterone. The first form of topical therapy has been a patch, but it has a quite 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 restricts its usage.

The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it has a tendency to be absorbed to good degrees in about 80% to 85 percent of men, but that leaves a significant number who don't absorb sufficient for it to have a positive impact. [For specifics on various formulations, see table ]

Are there any drawbacks to using dyes? How much time does it take for 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 are 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 the blood actually goes up quite fast, within several doses. I usually measure it after 2 weeks, even though symptoms may not alter for a month or two.

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