A Harvard expert shares his Ideas on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It might be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by approximately 1% per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone like lower sex drive and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as 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 is an underdiagnosed issue, with only about 5 percent of these affected receiving treatment.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may 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 ailments and male sexual and reproductive problems. He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and why he believes experts should reconsider the possible link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average person to see a physician?
As a urologist, I have a tendency to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is reduced 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 may experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally 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, but they're often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no question. However a decrease in orgasm intensity normally does not go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if somebody has less sex drive or less attention, it is more of a challenge to get a good erection.
How can 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 one is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a number. It's not like diabetes, where if your fasting glucose is above 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 receive testosterone therapy. Watch"Endocrine click here for info Society recommendations my website summarized." For a complete copy of these instructions, log on to www.endo-society.org. |
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 that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream is not available to cells. It's tightly 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. Though it's just a small fraction of this overall, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the correlation is greater compared to testosterone.
Endocrine Society recommendations summarizedThis professional organization urges testosterone treatment for men who have both Therapy Isn't Suggested for men who have
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