Finding Real-World Programs Of hrt

A Harvard Specialist shares his Ideas on testosterone-replacement therapy

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 aids cognition.

As time passes, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels start to fall, by approximately 1% 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, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with just about 5 percent of those affected undergoing therapy.

But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face.

Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate ailments and male reproductive and sexual problems. He has developed particular expertise in treating lower 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 connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the average man to see a doctor?

As a urologist, I have a tendency to observe guys since they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a lesser amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.

The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing 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 that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, 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 decide if or not a man is a candidate for testosterone-replacement treatment?

There are just two ways we determine whether somebody has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Normally 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 amounts, 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 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, her latest blog log on to www.endo-society.org.

Is complete testosterone the right thing to be measuring? Or if we are measuring something else?

This is just another area of confusion and great discussion, but I don't 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 total testosterone, or all the testosterone in the human body. But about half of their testosterone that's circulating in the blood is not readily available to cells. It is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available portion of total testosterone is known as free testosterone, and it's readily available to cells. 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.

Endocrine Society recommendations summarized

This professional organization urges testosterone therapy for men who have

Therapy Isn't recommended for men who've

Prostate or breast cancer
a nodule on the prostate that may be felt during a DRE
a PSA higher than 3 ng/ml without further analysis
a hematocrit greater than 50% or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract infections

class III or IV heart failure.

Do time daily, diet, or other elements affect testosterone levels?

For many years, the recommendation has been to get a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. But the information behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and older over the course of this day. One reported no change in average testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably insufficient to affect diagnosis. Most guidelines nevertheless say it is important to do the test in the morning, however for men 40 and over, it probably doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m.

There are some rather interesting findings about dietary supplements. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to make any recommendations that are clear.

Exogenous vs. endogenous testosterone

Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending on the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects.

In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, all of the men had increased levels of testosteronenone reported any side effects during the year they were followed.

Because clomiphene citrate is not accepted by the FDA for use in males, little information exists regarding the long-term ramifications of taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes medication such as clomiphene citrate one of just a few options for men with low testosterone that wish to father children.

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 fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to baseline. [See"Exogenous vs. endogenous testosterone," above.]

Topical treatments help preserve a more uniform amount of blood testosterone. The first form of topical therapy has been a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area on their skin. That limits its use.

The most widely used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it tends to be absorbed to great degrees in about 80% to 85% of men, but leaves a substantial number who don't consume enough for it to have a favorable impact. [For details on several different formulations, see table ]

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

Men who start using the gels have to return in to have their testosterone levels measured again to make certain they're absorbing the proper quantity. Our target 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 a few doses. I normally measure it after two weeks, even though symptoms may not change for a month or two.

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