A Harvard Specialist shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It might be stated that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"machinery" that makes testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1% per year, starting in the 40s. As men get into their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone like lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with just about 5 percent of these affected receiving treatment.
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 sexual and reproductive difficulties. He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he believes experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical person to see a doctor?
As a urologist, I have a tendency to observe guys because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a lesser amount of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something that would usually be arousing.
The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go together with it either, though surely 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 man is a candidate for testosterone-replacement treatment?
There are two ways we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.
Looking at the biochemical numbers, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. But no one really agrees on a number. It is similar to diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and click reference should not receive testosterone therapy. For a complete copy of the guidelines, log discover this info here on see this website to www.endo-society.org. |
Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?
Well, this is just another area of confusion and good debate, but I do not think it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. However, about half of their testosterone that's circulating in the bloodstream is not readily available to cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The biologically available part of overall testosterone is called free testosterone, and it's readily available to cells. Even though it's only a little portion of this overall, the free testosterone level is a fairly good indicator of low testosterone. It's not perfect, but the significance is greater compared to testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone treatment for men who have both Therapy is not Suggested for men who've
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