A Harvard expert shares his Ideas on testosterone-replacement therapy
A meeting 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, differentiating 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 aids cognition.
Over time, the "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 reduced libido and sense of energy, erectile dysfunction, diminished energy, reduced 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" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with just about 5% of these affected receiving treatment.
Various studies have revealed that testosterone-replacement therapy may offer a wide selection of benefits for men with hypogonadism, including 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 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 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 uses with his own patients, and why he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical person to find a doctor?
As a urologist, I tend to see men because they have sexual complaints. The primary hallmark of low testosterone is low 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 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 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, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally 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 attention, it's more of a challenge to have a good erection.
How do you decide if or not a man is a candidate for testosterone-replacement therapy?
There are just two ways 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 ideal. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. But there are some guys who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one really agrees on a number. It's similar to diabetes, where if your fasting glucose is over a certain level, they'll 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. Watch"Endocrine Society recommendations summarized." For a complete visite site copy of the guidelines, log 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 debate, but I do not think it's as confusing as it is apparently in the literature. When most physicians 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 blood is not readily available to the cells. The available portion of overall testosterone is called free testosterone, and it is readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's just a small fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the correlation is greater compared to total testosterone.
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