A Harvard expert shares his Ideas on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It might be stated that testosterone is what makes guys, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" which makes testosterone gradually becomes less effective, and testosterone levels start to drop, by about 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with only about 5% of those 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 ailments and male reproductive and sexual problems. He has developed particular 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 why he believes experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the typical man to find a doctor?
As a urologist, I have a tendency to observe guys because they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much lesser quantity of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.
The more of the symptoms there are, 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 decreasing testosterone levels.
Are not those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs which may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can 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 attention, it's more of a struggle to get a fantastic erection.
How can you determine if a person is a candidate for testosterone-replacement therapy?
There are just two ways that 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 these two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are some guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really agrees on a number. It's similar to diabetes, where if your fasting glucose is over 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 visit site should not receive testosterone therapy. For a complete copy of address the instructions, log browse around here on to www.endo-society.org. Is total testosterone the right point to be measuring? Or if we are measuring something else? Well, this is just another area of confusion and great discussion, but I do not think 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 the testosterone in the human body. However, about half of the testosterone that is circulating in the bloodstream is not readily available to the 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 called free testosterone, and it's readily available to the cells. Even though it's just a little fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.
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