Rudimentary Aspects Of testosterone therapy Considered

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

It might be said that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing 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. Additionally, it 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% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance 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 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.

He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his 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 doctor?

As a urologist, I tend to see men since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and any guy 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 these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.

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

Not exactly. There are a number of drugs which may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally doesn't go together 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 have a good erection.

How do you decide if a man is a candidate for testosterone-replacement therapy?

There are just two ways we determine whether someone has reduced testosterone. One is a blood test and the other 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 numbers, The Endocrine Society* believes low testosterone for 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 few. It's not like diabetes, in which if your fasting glucose is above a certain level, they will 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 receive testosterone therapy. For a complete copy of the instructions, log on to www.endo-society.org.

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

Well, this is 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 learned about overall testosterone, or all of the testosterone in the body. However, about half of the testosterone that's circulating in the blood is not readily available to the cells. It is tightly bound to a copyright molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The 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 significance is greater than with testosterone.

Endocrine Society recommendations outlined

This professional organization urges testosterone therapy for men who have

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 symptoms

class III helpful resources or IV heart failure.

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

For years, the recommendation was to get a testosterone value early in the morning because levels begin to drop after 10 or even 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and older within 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 not enough to influence identification. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and over, it likely doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m.

There are some rather interesting findings about dietary supplements. By way of example, it seems that individuals who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been studied thoroughly enough to make any recommendations that are clear.

Exogenous vs. endogenous testosterone

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

In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, 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 carrying it (such as the probability of developing prostate cancer) or if it's more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who want to father children.

Formulations

What forms of testosterone-replacement therapy are available? *

The oldest form is an injection, which we use since it's inexpensive and because we faithfully become fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to research.

Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a red area in their skin. That restricts its use.

The most commonly used testosterone preparation from the United States -- and also 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 has a tendency to be consumed to good levels in about 80% to 85 percent of guys, but leaves a substantial number who do not consume enough for this to have a favorable effect. [For specifics on several different 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 own testosterone levels measured again to make certain they are absorbing the right quantity. Our goal is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in 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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