A Harvard expert shares his Ideas on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be said that testosterone is what makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from women. 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 production of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which makes testosterone slowly 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 libido and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed issue, with only about 5% of these affected receiving treatment.
Various studies have shown that testosterone-replacement therapy may provide a wide selection of benefits for men with hypogonadism, such as 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 can stimulate prostate cancer.
He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his own patients, and he thinks specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical person to see a physician?
As a urologist, I tend to observe guys because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not usually go together with it , though certainly if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How can you decide whether a person is a candidate for testosterone-replacement treatment?
There are just two ways that we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. However, there are some men who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. But no one quite agrees on a number. It's not like diabetes, where 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 recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. Watch"Endocrine Society recommendations summarized." For a complete copy of these instructions, pop over here log on this website to www.endo-society.org. Is total testosterone the right thing to be measuring? Or if we are measuring something different? This is just another area of confusion and good discussion, but I don't think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the human body. However, about half of the testosterone that's circulating in the bloodstream is not readily available to cells. The available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Almost every lab has a blood test to measure free testosterone. Even though it's just a little portion of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not perfect, but the correlation is greater than with testosterone.
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