Programs In testosterone therapy - An Analysis

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

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

Over time, the "machinery" that makes testosterone slowly becomes less powerful, and testosterone levels begin to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like lower 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" speaking to the testicles). Yet it is an underdiagnosed issue, with just about 5% of those affected undergoing therapy.

Studies have shown that testosterone-replacement therapy may provide a vast selection of advantages for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists about 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 ailments and male sexual and reproductive difficulties. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his own patients, and why he thinks specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the average person to find 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 guy who complains of erectile dysfunction must possess his testosterone level checked. Men may experience other symptoms, such as more trouble 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 you will find, the more probable 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 guys have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications 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. But a decrease in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, it's more of a struggle to have a good erection.

How do you determine whether or not a man is a candidate for testosterone-replacement therapy?

There are just two ways that we determine whether somebody 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 guys with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. But there are some guys who have low levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one quite agrees on a few. It's similar to diabetes, in which if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not like this receive testosterone therapy. Watch"Endocrine Society recommendations summarized."

Is complete testosterone the ideal thing to be measuring? Or if we are measuring something else?

Well, this is just another area of confusion and good discussion, but I don't think that 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 of the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream is not readily available to the cells. It's tightly 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. 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 testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone therapy for men who have

Therapy Isn't Suggested for men who have

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • a PSA higher than 3 ng/ml without additional 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 get a testosterone value early in the morning since 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 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 not enough to influence diagnosis. Most guidelines still say it's important to perform 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 5 or 6 p.m.

    There are a number of rather interesting findings about diet. For example, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched thoroughly enough to create any clear recommendations.

    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 formula, treatment 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 studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, termed endogenous testosterone, in men. Within four to six months, each one the men had heightened levels of testosterone; none reported any side effects throughout the year they had been followed.

    Since clomiphene citrate isn't 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 than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication 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 can be found? *

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

    Topical treatments help preserve a more uniform level of blood testosterone. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In one study, as many as 40% 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. According to my experience, it tends to be absorbed to great levels in about 80% to 85% of guys, but that leaves a substantial number who do not consume sufficient for it to have a positive impact. [For specifics on various formulations, see table ]

    Are there any drawbacks to using dyes? How long does it take for them to get the job done?

    Men who start using the gels have to return in to have their testosterone levels measured again to be sure they're absorbing the proper amount. Our goal is the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.

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