Vital Factors In trt Described

A Harvard Specialist shares his thoughts on testosterone-replacement Treatment

 

 

It could be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the growth of the genitals , 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 produces testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed problem, with only about 5 percent of these affected receiving treatment.

Various studies have revealed that testosterone-replacement therapy may offer a wide selection of advantages for men with hypogonadism, including 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 expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and why he believes experts should reconsider the possible link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt that the typical person to find a doctor?

As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser amount of fluid from 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, but they are often treatable and reversible by normalizing testosterone levels.

Aren't those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications 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 usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less attention, it is more of a struggle to get a good erection.

How can you decide if a man is a candidate for testosterone-replacement therapy?

There are just two ways we determine whether someone has reduced 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 ideal. Generally men with the lowest testosterone have the most symptoms and men 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 amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar 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 Discover More Here who should and shouldn't receive testosterone therapy.

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 great debate, 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 learned about total testosterone, or all of the testosterone in the body. However, about half of their testosterone that is circulating in the bloodstream isn't available to cells.

The biologically available part of overall testosterone is called free testosterone, and it is readily available to the cells. Nearly every lab has a blood test to measure free testosterone. Though it's only a little fraction of this total, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater compared to total testosterone.

This professional organization urges testosterone therapy for men who have

  • Reduced levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy is not Suggested for men who have

  • Breast or prostate cancer
  • a nodule on the prostate that can be felt during a DRE
  • that a PSA greater than 3 ng/ml without additional evaluation
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure.

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

    For many years, the recommendation has been to get a testosterone value early in the morning since levels begin to drop after 10 or 11 a.m.. However, the information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature within the course of the day. One reported no change in typical testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably insufficient to affect diagnosis. Most guidelines nevertheless say it is important to do the test in the morning, however for men 40 and over, it probably does not matter much, provided that they get their blood drawn before 5 or 6 p.m.

    There are a number of very interesting findings about diet. By way of instance, it appears that individuals that have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to create any recommendations that are clear.

    In the following guide, 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, decreased sperm count, increased red blood cell count, along with additional side effects.

    Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the creation of natural testosterone, termed endogenous testosterone, in men. Within four to six months, each one the men had increased levels of testosteronenone reported any side effects during the year they were followed.

    Since clomiphene citrate is not accepted by the FDA for use in males, little information exists regarding the long-term ramifications of taking 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 enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.

Formulations

What forms of testosterone-replacement therapy are available? *

The oldest form is an injection, which we still use since it is cheap and since we reliably get good testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and then return to research. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical treatments help maintain 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 red area on their skin. That restricts its use.

The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off with -- is a topical gel. According to my experience, it tends to be absorbed to great degrees in about 80% to 85% of men, but leaves a substantial number who don't consume sufficient for it to have a favorable effect. [For specifics on several different formulations, see table below.]

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

Men who start using the gels have to return in to have their testosterone levels measured again to make certain they are absorbing the proper quantity. Our target is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in the 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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