Essential Factors Of trt Revealed

A Harvard Specialist shares his Ideas on testosterone-replacement Treatment

An interview with Abraham Morgentaler, M.D.

It could 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 growth of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.

As time passes, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like lower libido 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 USA. Yet it's an underdiagnosed problem, 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 can stimulate prostate cancer.

He's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his patients, and why he believes specialists should rethink 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 physician?

As a urologist, I tend to see men because they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a lesser quantity of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something which would usually be arousing.

The more of the symptoms you will find, the more probable it is that a man has low testosterone. Many physicians often discount 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 men have when they're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of drugs that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it either, though surely if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.

How can you decide whether a person is a candidate for testosterone-replacement treatment?

There are just two ways that we determine whether somebody 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 highest testosterone have the least. However, there are a number of men who have low levels of testosterone in their blood and have no symptoms.

Looking at the biochemical numbers, The Endocrine Society* believes low testosterone for a total testosterone level of less than 300 ng/dl, and I think that is a sensible guide. However, no one quite agrees on a number. It is similar to diabetes, where if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as clear.

*Notice: 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 you can try this out on to www.endo-society.org.

Is total testosterone the ideal thing to be measuring? Or if we are measuring something different?

Well, this is just another area of confusion and great discussion, but I do not think it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream is not readily available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of overall testosterone is called free testosterone, and it is readily available to the cells. Even though it's just a small portion of the overall, the free testosterone level is a pretty good indicator of reduced testosterone. It's not ideal, but the correlation is greater than with total testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have both

Therapy Isn't recommended for men who've

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

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

    For years, the recommendation was to get a testosterone value early in the morning because levels begin to drop after 10 or even 11 a.m.. But the information behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and mature over the course of this day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a small amount, and probably not enough to affect diagnosis. Most guidelines nevertheless say it is important to do the test in the morning, however for men 40 and above, it likely does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

    There are some rather interesting findings about diet. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been studied thoroughly enough to make any recommendations that are clear.

    Exogenous vs. endogenous testosterone

    Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based upon the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.

    Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, also known as endogenous testosterone, in men. Within four to six months, each one the guys had heightened levels of testosterone; none reported any side effects throughout the entire year they had been followed.

    Since clomiphene citrate isn't approved by the FDA for use in men, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.

    What forms of testosterone-replacement therapy are available? *

    The earliest form is the injection, which we use because 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 few weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.]

    Topical treatments help preserve a more uniform level of blood testosterone. The first form of topical therapy was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area in their skin. That restricts its usage.

    The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. Based on my experience, it tends to be consumed to great degrees in about 80% to 85% of men, but leaves a significant number who don't absorb sufficient for it to have a positive effect. [For details on several different formulations, see table below.]

    Are there any drawbacks to using gels? How much time does it require them to get the job done?

    Men who start using the implants need to return in to have their testosterone levels measured again to make certain they are absorbing the right amount. Our target is that the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, in just a few doses. I normally measure it after two weeks, even though symptoms may not alter for a month or two.

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