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A Harvard Specialist shares his Ideas on testosterone-replacement therapy

It might be said that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.

As time passes, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like reduced libido and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with only about 5% of these affected receiving treatment.

Studies have shown that testosterone-replacement therapy can provide a vast selection of advantages for men with hypogonadism, including improved 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 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 specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt that the average man to find a physician?

As a urologist, I tend to observe guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience other symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would normally be arousing.

The more of the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.

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

Not precisely. There are quite a few drugs which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not usually go together with it , though surely if somebody has less sex drive or less interest, it is more of a challenge to get a fantastic erection.

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

There are two ways we determine whether someone has low 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 perfect. Generally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are some guys who have low levels of testosterone in their blood and have no signs.

Looking at the biochemical amounts, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that is a sensible guide. But no one really agrees on a few. It's similar to diabetes, in which if your fasting glucose 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 publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy.

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

This is another area of confusion and great discussion, but I do not think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. But about half of the testosterone that is circulating in the blood is not available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of total testosterone is called free testosterone, and it is readily available to cells. Though it's just a small portion of this total, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater than with total testosterone.

Endocrine Society recommendations outlined

This professional organization urges testosterone therapy for men who have both

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

Therapy Isn't Suggested for men who have

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • that a PSA greater than 3 ng/ml without further evaluation
  • a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III visit their website or discover this info here IV heart failure. here are the findings

    Do time of day, diet, or other factors influence testosterone levels?

    For years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to influence diagnosis. Most guidelines still say it's important to do the test in the morning, but for men 40 and over, it likely doesn't 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 dietary supplements. By way of example, it appears that individuals that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to make any clear recommendations.

    Within the following guide, testosterone-replacement treatment 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 production of natural testosterone, known as nitric oxide, in men. At 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 of the men had increased levels of testosteronenone reported any side effects throughout the entire year they were followed.

    Because clomiphene citrate isn't accepted by the FDA for use in men, little information exists regarding the long-term ramifications of carrying it (including the probability of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enhances -- sperm production. This makes drugs such as clomiphene citrate one of just a few options for men with low testosterone who wish to father children.

    What kinds of testosterone-replacement therapy are available? *

    The earliest form is the injection, which we still use since it is inexpensive and since we faithfully get fantastic testosterone levels in almost everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and return to research.

    Topical treatments help maintain a more uniform amount of blood testosterone. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a red area in their skin. That limits its use.

    The most widely used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it has a tendency to be absorbed to great levels in about 80% to 85% of guys, but leaves a substantial number who do not consume enough for this to have a favorable effect. [For details on several different formulations, see table below.]

    Are there any downsides 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 make certain they are absorbing the right quantity. 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 actually goes up quite fast, in just a few doses. I usually measure it after 2 weeks, even though symptoms may not alter for a month or two.

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