A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It might be said that testosterone is what 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 leads to normal erections. It also boosts the production of red blood cells, boosts mood, and assists cognition.
Over time, the testicular"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 might start to have symptoms and signs of low testosterone such as lower libido and sense of vitality, 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 functioning and"gonadism" speaking 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 issue, with only about 5% of these affected undergoing therapy.
Studies have shown that testosterone-replacement therapy can provide a wide range of advantages for men with hypogonadism, such as enhanced 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 diseases and male reproductive and sexual problems. He's developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own 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 some other 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 climaxes, a much 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 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 reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease 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 together with it , though certainly if somebody has less sex drive or less interest, it is more of a struggle to have a good erection.
How do you determine if or not a person is a candidate for testosterone-replacement therapy?
There are two ways 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 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 signs.
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 reasonable guide. But no one really agrees on a few. It's similar to diabetes, in which if your fasting glucose is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. For a complete copy of the instructions, investigate this site log on to www.endo-society.org. Is complete testosterone the right thing to be measuring? Or if we are measuring something else? Well, this is just another area of confusion and great debate, 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 heard about overall testosterone, or all the testosterone in the human body. But about half of the testosterone that is circulating in the bloodstream isn't available to the cells. It is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Almost every laboratory has a blood test to measure free testosterone. Even though it's just a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the correlation is greater than with testosterone. This professional organization recommends testosterone treatment for men who have both
Therapy is not Suggested for men who have
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