Finding Real-World Programs Of hrt

A Harvard expert shares his Ideas on testosterone-replacement Treatment

An interview with Abraham Morgentaler, M.D.

It might be said that testosterone is the thing that makes men, guys. 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 at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" which makes testosterone slowly becomes less effective, and testosterone levels begin to fall, by about 1% per year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like 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 referred to as hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed issue, with only 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.

Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate diseases and male reproductive and sexual problems. He has developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his patients, and he thinks specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see guys since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid from ejaculation, and a feeling of numbness in the manhood 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 dismiss these"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 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 amount of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it either, though certainly if a person has less sex drive or less interest, it's more of a challenge to get a good erection.

How do you decide if or not a person is a candidate for testosterone-replacement therapy?

There are two ways that we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. But there are some guys who have reduced 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 think that's a reasonable guide. However, no one really agrees on a number. It's not like diabetes, in which if your fasting glucose 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.

Is total testosterone the ideal point to be measuring? Or should we be measuring something else?

This is another area of confusion and good discussion, but I don't think that it's as confusing as it is apparently in 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. But about half of their testosterone that's circulating in the bloodstream isn't available to the cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of total testosterone is known as 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 pretty good indicator of reduced testosterone. It is not ideal, but the significance is greater than with testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone treatment for men who have both

Therapy Isn't Suggested for men who have

  • Prostate or breast cancer
  • a nodule on the prostate that may be felt during a DRE
  • a PSA higher than 3 ng/ml without further analysis
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III official source or IV heart failure.

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

    For years, the recommendation has been to receive a testosterone value early in the morning because levels start to fall after 10 or 11 a.m.. But the information behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older 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 not enough to affect identification. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and above, it likely doesn't matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

    There are some rather interesting findings about dietary supplements. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.

    Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based on the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects.

    In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, all of the guys had increased levels of testosteronenone reported some side effects throughout the entire year they had been followed.

    Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists regarding the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication like clomiphene citrate one of only a few choices for men with low testosterone who want to father children.

Formulations

What forms of testosterone-replacement therapy can be found? *

The earliest form is the injection, which we still use since it's inexpensive and because we reliably become fantastic testosterone levels in almost everybody. The disadvantage is that a person needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to baseline.

Topical treatments help preserve a more uniform level of blood testosterone. The first kind of topical treatment has been a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a reddish area on their skin. That limits its usage.

The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off -- is a topical gel. The gel comes in tiny tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be consumed to good levels in about 80% to 85 percent of men, but that leaves a significant number who do not absorb sufficient for it to have a positive impact. [For specifics on various formulations, see table ]

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

Men who begin using the gels have to come back in to have their own testosterone levels measured again to make certain they are absorbing the right quantity. Our target is the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.

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