A Harvard expert shares his Ideas on testosterone-replacement therapy
It could be said that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it boosts the production of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which produces testosterone slowly becomes less effective, and testosterone levels begin to drop, by approximately 1 percent a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they might 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 anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low working and"gonadism" speaking to the testicles). Yet it is an underdiagnosed problem, with just about 5% of these affected receiving treatment.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. Much of the current debate focuses on the long-held belief that testosterone can stimulate prostate cancer.
He's developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his patients, and why he believes specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average man to find a doctor?
As a urologist, I tend to see men since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a much smaller amount of fluid from ejaculation, and a sense of numbness in the penis 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 tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications that may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly 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 a person is a candidate for testosterone-replacement therapy?
There are two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one really agrees on a few. It's similar to diabetes, in which if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't see here now receive testosterone therapy. Is total testosterone the ideal point to be measuring? Or if we are measuring something different? This is 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 human body. But about half of the testosterone that's circulating in the bloodstream is not readily available to cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Even though it's only a little portion of this total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the correlation is greater compared to total testosterone.
Do time daily, diet, or other elements influence testosterone levels? For many years, the recommendation has been to receive a testosterone value early in the morning because levels start to fall after 10 or even 11 a.m.. However, the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older within the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a modest amount, and probably insufficient to influence diagnosis. Most guidelines still say it's important to do the test in the morning, however for men 40 and over, it probably does not matter much, provided that they get their blood drawn before 6 or 5 p.m. There are some very interesting findings about dietary supplements. By way of example, it seems that those who 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.
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