Real-World trt Programs For 2012

A meeting with Abraham Morgentaler, M.D.

It could be stated that testosterone is what makes guys, men. 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 , plays a role in sperm production, fuels libido, and leads to normal erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.

As time passes, the "machinery" which makes testosterone gradually becomes less effective, and testosterone levels begin 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 such as reduced libido and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with just about 5% of these affected undergoing therapy.

Various studies have revealed that testosterone-replacement therapy may offer a vast range of benefits for men with hypogonadism, such as 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 risks 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 reproductive and sexual difficulties. He's developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he thinks specialists should rethink the potential link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to see guys since they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much smaller quantity of fluid from ejaculation, and a sense of numbness in the penis 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 discount those"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 men have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of drugs which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally does not 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 is more of a struggle to have a good erection.

How can you determine if a person 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 symptoms and signs, and the correlation between these two approaches is far from ideal. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are a number of guys 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 for a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. But no one really agrees on a few. It is similar to diabetes, where if your fasting sugar is above 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 treatment. See"Endocrine Society recommendations summarized."

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

Well, this is just another area of confusion and great debate, but I don't think that it's as confusing as it appears to be from the literature. When most physicians 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 is circulating in the blood is not readily available to the cells.

The biologically available portion of total testosterone is known as free testosterone, and it's readily available to cells. Almost every lab has a blood test to measure free testosterone. Even though it's just a little portion of this overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not ideal, but the correlation is greater than with testosterone.

Endocrine Society recommendations outlined This professional organization recommends testosterone therapy for men who have Reduced levels of testosterone in the blood (less than 300 ng/dl) symptoms of low testosterone. Therapy Isn't recommended for men who've Breast or prostate cancer a nodule on the prostate which may be felt during a DRE that a PSA greater than 3 ng/ml without additional evaluation that a hematocrit greater than 50% or thick, viscous blood untreated obstructive sleep apnea severe lower urinary tract symptoms class III or IV Learn More Here heart visit this website failure. Do time of day, diet, or other factors 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 even 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of the day. One reported no change in typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a small sum, and probably not enough to influence identification. Most guidelines nevertheless say it is important to do the evaluation in the morning, but for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 5 or 6 p.m. There are some rather interesting findings about dietary supplements. For instance, it appears that those that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to make any recommendations that are clear. In the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects. Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the production of natural testosterone, 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 months, each one of the men had increased levels of testosterone; none reported any side effects during the year they had been followed. Since clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the risk of developing prostate cancer) or whether it is more capable of boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes drugs such as clomiphene citrate one of only a few choices for men with low testosterone who want to father children.

Formulations

What kinds of testosterone-replacement therapy are available? *

The oldest form is an injection, which we still use since it's cheap and since we faithfully become fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to research.

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

The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes from tiny tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be absorbed to good degrees in about 80% to 85 percent of men, but that leaves a significant number who do not absorb enough for this to have a positive effect. [For specifics on several different formulations, see table ]

Are there any downsides to using dyes? How long does it take for them to work?

Men who begin using the gels have to come back in to have their testosterone levels measured again to make sure they're absorbing the proper amount. Our target is the mid to upper range 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 change for a month or two.