Clarifying Vital Elements For trt

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, 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 fosters the creation of red blood cells, boosts mood, and aids cognition.

Over time, the "machinery" which makes testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1% a year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as lower 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 called 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's an underdiagnosed problem, with just about 5% of these affected undergoing therapy.

But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face.

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 problems. He's developed specific experience in treating lower 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 potential 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 physician?

As a urologist, I tend to see guys since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something which 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 dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.

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

Not precisely. There are a number of medications which may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount 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 ordinarily go along with it , though surely if somebody has less sex drive or less attention, it's more of a challenge to get a good erection.

How can you determine whether or not a person is a candidate for testosterone-replacement treatment?

There are 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 these two approaches is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.

Looking 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 reasonable guide. However, no one quite agrees on a number. It is not like diabetes, in which if your fasting sugar is over 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 find more info and should check this site out not receive testosterone my sources treatment. For a complete copy of the guidelines, log on to www.endo-society.org.

Is complete testosterone the right point to be measuring? Or if we are measuring something else?

This is another area of confusion and good discussion, but I do not think that it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the human body. However, about half of the testosterone that's circulating in the blood isn't readily available to cells.

The available portion of overall testosterone is called free testosterone, and it's readily available to cells. Though it's only a little portion of the overall, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater compared to testosterone.

Endocrine Society recommendations summarized This professional organization urges testosterone therapy for men who have both Reduced levels of testosterone in the blood (less than 300 ng/dl) symptoms of low testosterone. Therapy is not recommended for men who have Prostate or breast cancer a nodule on the prostate which can be felt during a DRE 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 or IV heart failure. Do time of day, diet, or other factors affect testosterone levels? For years, the recommendation has been to get a testosterone value early in the morning because levels start to fall after 10 or even 11 a.m.. But the data behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature within the course of this day. One reported no change in typical testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably insufficient to influence identification. Most guidelines nevertheless say it's important to do the test in the morning, however for men 40 and above, it likely doesn't matter much, provided that they get their blood drawn before 5 or 6 p.m. There are a number of very interesting findings about dietary supplements. By way of instance, it appears that those that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear. Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending on the formulation, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects. Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, also termed endogenous testosterone, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, all the guys had increased levels of testosterone; none reported some side effects during the year they were followed. Since clomiphene citrate isn't accepted 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 compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone who wish to father children.

Formulations

What kinds of testosterone-replacement treatment can be found? *

The earliest form is the injection, which we still use because it's inexpensive and since we reliably get fantastic testosterone levels in almost everybody. The disadvantage is that a man should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to research. [See"Exogenous vs. endogenous testosterone," above.]

Topical therapies help preserve a more uniform amount of blood glucose. The first kind of topical therapy was a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a reddish 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 -- is a topical gel. The gel comes in tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be consumed to great levels in about 80% to 85% of guys, but leaves a significant number who do not absorb sufficient for this to have a favorable impact. [For details on several different formulations, see table below.]

Are there any downsides to using dyes? How much time 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 proper quantity. Our goal is that the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just several doses. I usually measure it after two weeks, even though symptoms may not change for a month or two.