A Harvard expert shares his Ideas on testosterone-replacement Treatment
It might be said that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" that produces testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1% a 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 such as reduced 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 functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with only about 5 percent of those affected undergoing therapy.
Various studies have shown that testosterone-replacement therapy can provide a vast range of advantages for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 difficulties. He has 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 why he thinks specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical person to find a physician?
As a urologist, I have a tendency to see men because they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense orgasms, 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 these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss 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 precisely. There are quite a few 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 doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, it is more of a struggle to have a fantastic erection.
How can you decide whether a person is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether someone has reduced 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 have 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 amounts, The Endocrine Society* believes low testosterone for a total 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 similar to 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 clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. For a complete copy of these 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 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 body. But about half of their testosterone that's circulating in the blood isn't available to cells. It is tightly 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 cells. Even though it's just a small 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 summarizedThis professional organization urges testosterone therapy for men who have
Therapy Isn't recommended for men who've
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