A Harvard expert shares his Ideas on testosterone-replacement Treatment
It could be stated 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 at puberty, 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.
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 like lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning 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% of those affected undergoing therapy.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers 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 diseases and male reproductive and sexual problems. He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement treatment 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 reduced 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 other symptoms, such as more difficulty 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 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.
Aren't those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less interest, it is more of a struggle to have a fantastic erection.
How do you determine whether a man is a candidate for testosterone-replacement therapy?
There are two ways we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one quite agrees on a few. It is not like diabetes, where if your fasting sugar is above 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 publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. check out here For a complete copy of the guidelines, log on to www.endo-society.org. Is total testosterone the ideal point to be measuring? Or should we be measuring something else? This is just another area of confusion and great debate, but I do not think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the human body. But about half of their testosterone that is circulating in the bloodstream isn't available to cells. It's closely bound to a carrier molecule called 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. 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.
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