Painless testosterone therapy Plans - What's Needed
An interview with Abraham Morgentaler, M.D.
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 percent a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness 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.
But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
He's developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his patients, and why he thinks specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.Symptoms and diagnosis
What signs and symptoms 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 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 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 very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications which may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually does not go along 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's more of a struggle to have a fantastic erection.
How do you determine whether or not a person is a candidate for testosterone-replacement treatment?
There are 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 those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. However, there are some men who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that is a reasonable guide. But no one really agrees on a few. It's not like diabetes, in which 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 apparent.
|*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. sites |
Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?
This is another area of confusion and good debate, but I do not think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the human body. However, about half of the testosterone that is circulating in the bloodstream isn't readily available to cells.
The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Nearly every lab has a blood test to measure free testosterone. 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 compared to testosterone.
This professional organization urges testosterone therapy for men who have
Therapy Isn't Suggested for men who have
Do time of day, diet, or other elements affect testosterone levels?
For many years, the recommendation was to get a testosterone value early in the morning since levels start to fall after 10 or even 11 a.m.. But the information behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older within the course of the day. One reported no change in average testosterone till after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably not enough to affect diagnosis. Most guidelines still say it is important to perform the test in the morning, however for men 40 and over, it probably doesn't matter much, provided that they get their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about dietary supplements. By way of example, it appears that individuals that 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.
In the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is manufactured outside the body. Depending upon the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and additional side effects.
Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the production of natural testosterone, known as nitric oxide, in men. Within four to six months, each one the guys had increased levels of testosteronenone reported any side effects during the year they were followed.
Because clomiphene citrate is not approved by the FDA for use in males, little information exists regarding the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enriches -- sperm production. This makes medication such as clomiphene citrate one of just a few options for men with low testosterone who want to father children.Formulations
What forms of testosterone-replacement therapy are available? *
The earliest form is the injection, which we use because it's inexpensive and because we reliably become good testosterone levels in nearly everybody. The disadvantage is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can 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 quite high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a reddish area in their skin. That limits 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. Based on my experience, it has a tendency to be consumed to good levels in about 80% to 85 percent of men, but that leaves a substantial number who don't absorb sufficient for it to have a favorable impact. [For details on various formulations, see table ]
Are there any drawbacks to using dyes? How long 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 be sure they're absorbing the proper amount. Our goal is the mid to upper assortment of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, within several doses. I usually measure it after two weeks, even though symptoms may not alter for a month or two.