Considering Rapid Systems In testosterone therapy

A Harvard expert shares his thoughts on testosterone-replacement Treatment

An interview with Abraham Morgentaler, M.D.

It could be said 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 fosters the production of red blood cells, boosts mood, and aids cognition.

Over time, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Yet it's an underdiagnosed issue, with just about 5 percent of these affected undergoing therapy.

Various studies have shown that testosterone-replacement therapy may offer a vast selection of advantages for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on 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 may stimulate prostate cancer.

He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his patients, and he believes specialists should rethink the possible connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction should get his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.

The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to discount these"soft symptoms" as a normal part of aging, however, 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 precisely. There are a number of medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally 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 good erection.

How can you determine if a person is a candidate for testosterone-replacement therapy?

There are just two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.

Looking at the biochemical numbers, The Endocrine Society* believes 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 few. It is not like diabetes, in which if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive have a peek here testosterone treatment. check my blog For a complete copy of the instructions, log on to read this article www.endo-society.org.

Is complete 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 it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. But about half of their testosterone that is circulating in the blood is not available to the cells. It is closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available part of total testosterone is known as free testosterone, and it is readily available to cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of low testosterone. It's not ideal, but the significance is greater than with total testosterone.

Endocrine Society recommendations outlined

This professional organization urges testosterone therapy for men who have both

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

Therapy is not recommended for men who've

Breast or prostate cancer
a nodule on the prostate which can be felt during a DRE
a PSA greater than 3 ng/ml without further evaluation
a hematocrit greater than 50% 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 elements influence testosterone levels?

For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within the course of the day. One reported no change in average testosterone until after 2 Between 2 and 6 p.m., it went down by 13%, a small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it's important to do the test in the morning, but for men 40 and over, it likely does not matter much, as long as they get their blood drawn before 5 or 6 p.m.

There are some very interesting findings about dietary supplements. By way of instance, it appears that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been researched thoroughly enough to make any clear recommendations.

Exogenous vs. endogenous testosterone

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

Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, termed nitric oxide, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, each one of the guys had increased levels of testosteronenone reported any side effects throughout the year they were followed.

Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it's more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children.

Formulations

What forms of testosterone-replacement treatment are available? *

The earliest form is an injection, which we use since it's cheap and because we reliably become good testosterone levels in almost everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood glucose levels peak and then return to research.

Topical treatments help preserve a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a red area on their skin. That restricts its use.

The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes in tiny tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be consumed to good degrees in about 80% to 85 percent of men, but leaves a significant number who don't consume sufficient for it to have a favorable impact. [For specifics on various formulations, see table ]

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

Men who begin using the gels have to return in to have their own testosterone levels measured again to make sure they are absorbing the proper 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 really goes up quite fast, in just a few doses. I normally measure it after two weeks, even although symptoms may not change for a month or two.

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