A Harvard Specialist shares his thoughts on testosterone-replacement therapy
It could be said that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also fosters the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by about 1% per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Yet it's an underdiagnosed problem, with just about 5% of those 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 can 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 difficulties. He's developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he thinks specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical person to see a physician?
As a urologist, I tend to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of 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 there are, the more probable it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.
Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no question. However a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily 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 man is a candidate for testosterone-replacement therapy?
There are just two ways we determine whether someone has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between these two approaches is far from ideal. Normally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a number. It's not like diabetes, where if your fasting glucose is above a certain level, they'll 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 should i loved this not receive testosterone treatment. For redirected here a complete copy of these instructions, log on to www.endo-society.org. Is total testosterone the right thing to be measuring? Or should we be measuring something else? Well, this is another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. However, about half of their testosterone that is circulating in the bloodstream is not available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Though it's just a small fraction of this overall, 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.
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