Programs In hrt - An Analysis

A Harvard expert shares his thoughts on testosterone-replacement Treatment

A meeting with Abraham Morgentaler, M.D.

It could be stated that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.

As time passes, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, 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.

Various studies have shown that testosterone-replacement therapy may provide a vast range of benefits for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 own patients, and why he believes specialists should rethink the possible link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt that the typical person to find a physician?

As a urologist, I have a tendency to observe 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 any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid out of ejaculation, and a sense 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 are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications which may reduce libido, such as the BPH medication 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 does not 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 interest, it is more of a struggle to have a fantastic erection.

How do you determine whether or not a person is a candidate for testosterone-replacement treatment?

There are just two ways we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are some guys who have reduced levels of testosterone in their blood and have no signs.

Looking purely 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 is a reasonable guide. But no one really agrees on a number. 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 apparent.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. See"Endocrine Society recommendations summarized." For a complete copy click here to read of the instructions, 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 debate, but I do not think it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the human body. But about half of their testosterone that's circulating in the bloodstream isn't available to cells.

The available part of overall testosterone is called free testosterone, and it is readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's just a small portion of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the significance is greater than with testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have both

Therapy is not 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 analysis
  • a hematocrit greater than 50 percent 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 start to fall after 10 or 11 a.m.. But the information behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of this day. One reported no change in average testosterone until after 2 Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably insufficient to influence identification. Most guidelines nevertheless say it's important to do the evaluation in the morning, but for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

There are a number of very interesting findings about dietary supplements. By way of example, it appears that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to create any recommendations that are clear.

Exogenous vs. endogenous testosterone

Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Depending on the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional 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, known as nitric oxide, in men. Within four to six months, each one the guys had increased levels of testosteronenone reported some side effects throughout 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 taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication such as clomiphene citrate one of just a few options for men with low testosterone that wish to father children.

What kinds of testosterone-replacement treatment can be found? *

The earliest form is the injection, which we use because it's inexpensive and because we reliably get good testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also happen as blood glucose levels peak and return to baseline.

Topical treatments help preserve a more uniform amount of blood testosterone. The first form of topical therapy was a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area on their skin. That limits its use.

The most widely used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be consumed to great degrees in about 80% to 85 percent of men, but that leaves a substantial number who do not consume enough for it to have a positive impact. [For details on various formulations, see table below.]

Are there any drawbacks to using dyes? How much time does it take for them to work?

Men who start using the implants need to return in to have their testosterone levels measured again to make sure they are absorbing the right amount. Our goal is the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, in just several doses. I usually measure it after 2 weeks, even though symptoms may not change for a month or two.

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