Criteria Of trt - Insights

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

 

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, big muscles, and facial and body hair, differentiating 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 boosts the production of red blood cells, boosts mood, and assists cognition.

As time passes, the "machinery" which makes testosterone gradually becomes less powerful, and testosterone levels start to drop, 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 sex drive and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with just about 5% of those affected undergoing therapy.

 

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 sexual and reproductive difficulties. He has developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and he thinks specialists should rethink the possible link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the typical person to find a physician?

As a urologist, I have a tendency to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid out of 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 often discount those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.

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

Not exactly. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally does not go along with treatment for BPH. Erectile dysfunction does not usually go along with it , though certainly if somebody has less sex drive or less interest, it's more of a challenge to get a good erection.

How can you decide if a man is a candidate for testosterone-replacement therapy?

There are two ways we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. However, there are a number of men who have low levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one quite agrees on a few. It is not like diabetes, where if your fasting sugar is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not Source receive testosterone treatment. See"Endocrine Society recommendations summarized." For a complete copy of the guidelines, log on to www.endo-society.org.

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

This is another area of confusion and good debate, but I do not think it's as confusing as it appears to be from 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 their testosterone that's circulating in the blood is not readily available to cells.

The biologically available part of overall testosterone is called free testosterone, and it is readily available to the cells. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with testosterone.

Endocrine Society recommendations outlined

This professional organization recommends testosterone treatment for men who have both

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

Therapy is not Suggested for men who have

  • Breast or prostate cancer
  • a nodule on the prostate which can 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 infections
  • class III or IV heart failure.

Do time daily, diet, or other factors affect testosterone levels?

For many years, the recommendation has been to get a testosterone value early in the morning since levels start to fall after 10 or even 11 a.m.. But the information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature over 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%, a modest sum, and probably insufficient to influence identification. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

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

Exogenous vs. endogenous testosterone

Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's manufactured outside the body. Depending on the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.

Within four to six weeks, all of the men had heightened levels of testosteronenone 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 about the long-term effects of taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.

Formulations

What forms of testosterone-replacement therapy are available? *

The earliest form is the injection, which we use since it is cheap and since we reliably get good testosterone levels in nearly everybody. The drawback is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical treatment was 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 red area on their skin. That restricts its usage.

The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. Based on my experience, it has a tendency to be consumed to good levels in about 80% to 85 percent of guys, but that leaves a substantial 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 require them to get the job done?

Men who start using the implants need to return in to have their testosterone levels measured again to be certain they're absorbing the proper amount. Our goal is that the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, within several doses. I usually measure it after 2 weeks, although symptoms may not alter for a month or two.

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