Finding Real-World Programs Of testosterone therapy

A Harvard expert shares his thoughts on testosterone-replacement Treatment

It could be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big muscles, and body and facial 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 production of red blood cells, boosts mood, and assists cognition.

As time passes, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels begin to fall, by approximately 1% per year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone like lower libido 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 functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed problem, with only about 5% of these affected receiving treatment.

Studies have revealed that testosterone-replacement therapy can offer a wide range of advantages for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 may stimulate prostate cancer.

He's 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 patients, and he thinks specialists should rethink the possible connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt the typical man to see a doctor?

As a urologist, I tend to observe guys because they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men can experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a smaller amount of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something that would normally be arousing.

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

Aren't those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of medications which may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it , though surely if somebody has less sex drive or less interest, it is more of a challenge to have a good erection.

How can you determine if or not a man is a candidate for testosterone-replacement treatment?

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 maximum testosterone have the least. However, there are a number of men who have reduced levels of testosterone in their blood and have no signs.

Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a sensible guide. However, no one quite agrees on a few. It is similar to diabetes, where if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as clear.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should i thought about this and shouldn't receive testosterone treatment. my response For a complete copy of these guidelines, log on to www.endo-society.org.

Is complete testosterone the right thing to be measuring? Or should we be measuring something else?

Well, this is just another area of confusion and great debate, 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 heard about overall testosterone, or all the testosterone in the body. But about half of their testosterone that is circulating in the bloodstream isn't available to cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of overall testosterone is known as free testosterone, and it's readily available to cells. Even though it's only a little fraction of this overall, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the correlation is greater than with testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone treatment for men who have

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

Therapy Isn't Suggested for men who have

Breast or prostate cancer
a nodule on the prostate which can be felt during a DRE
that a PSA higher than 3 ng/ml without further analysis
that 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 of day, diet, or other factors influence testosterone levels?

For many years, the recommendation was to get a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. But the information behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of the day. One reported no change in typical testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a small amount, and probably not enough to affect diagnosis. Most guidelines still say it is important to perform the evaluation in the morning, but for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.

There are some very interesting findings about diet. By way of instance, it appears that individuals who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been researched thoroughly enough to make any clear recommendations.

Exogenous vs. endogenous testosterone

In this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is manufactured outside the body. Depending upon the formulation, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects.

Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the creation of natural testosterone, also known as endogenous testosterone, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, each one the guys had increased levels of testosterone; none reported some side effects during the entire year they were followed.

Since clomiphene citrate isn't approved by the FDA for use in males, little information exists regarding the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it's more effective at boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enhances -- sperm production. That makes medication like clomiphene citrate one of just a few options for men with low testosterone that wish to father children.

What kinds of testosterone-replacement therapy are available? *

The oldest form is an injection, which we still use because it is cheap and because we reliably become good testosterone levels in nearly everybody. The disadvantage is that a man 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 then return to research.

Topical treatments help preserve a more uniform amount of blood glucose. The first form of topical treatment has been a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area in their skin. That restricts its use.

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. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be consumed to good levels in about 80% to 85% of guys, but leaves a substantial number who don't absorb sufficient for it to have a favorable effect. [For specifics on several different formulations, see table ]

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

Men who begin using the gels have to return in to have their testosterone levels measured again to be certain they are absorbing the proper quantity. Our goal is that 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, in just a few doses. I usually measure it after 2 weeks, even although symptoms may not change for a month or two.

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