An interview with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels start to drop, by about 1 percent per year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like reduced 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" significance low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed problem, with just about 5 percent of these affected receiving treatment.
He's developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his own patients, and he believes experts should reconsider the possible link between testosterone-replacement treatment and prostate cancer.Symptoms and diagnosis
What symptoms and signs of low testosterone prompt the typical man to find a physician?
As a urologist, I have a tendency to observe men since they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a much smaller quantity of fluid out of ejaculation, and a feeling of numbness in the manhood 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 tend to discount these"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.
Are not those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs which may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally does not go along with therapy for BPH. Erectile dysfunction does not usually go together with it , though surely if a person has less sex drive or less interest, it's more of a struggle to get a good erection.
How do you determine if or not a man is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two approaches is far from ideal. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are some guys who have reduced levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really 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 isn't quite as clear.
|*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who Visit This Link should and shouldn't receive testosterone therapy. For Resources a complete copy of the instructions, log on you could try these out to www.endo-society.org.|
Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?
Well, this is another area of confusion and good discussion, but I don't think it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the human body. But about half of their testosterone that's circulating in the bloodstream is not readily available to the cells.
The biologically available part of overall testosterone is known as free testosterone, and it's readily available to the cells. Even though it's just a small fraction of this total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the significance is greater than with testosterone.
This professional organization urges testosterone treatment for men who have
Therapy Isn't recommended for men who've
- Breast or prostate cancer
- a nodule on the prostate which can be felt during a DRE
- a PSA higher than 3 ng/ml without additional evaluation
- 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 of day, diet, or other elements affect testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. But the information behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of this day. One reported no change in typical testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13%, a small sum, and probably not enough to affect diagnosis. Most guidelines still say it is important to do the evaluation in the morning, but for men 40 and over, it likely doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are a number of rather interesting findings about dietary supplements. For example, it appears that individuals that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been studied thoroughly enough to create any clear recommendations.
Within this article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending upon the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with 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, also termed nitric oxide, in men. Within four to six months, each one the men had increased levels of testosteronenone reported some side effects throughout the year they had been followed.
Since clomiphene citrate isn't approved by the FDA for use in males, little information exists regarding the long-term effects of carrying it (including 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 enhances -- sperm production. This makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone that want to father children.Formulations
What kinds of testosterone-replacement treatment can be found? *
The earliest form is the injection, which we still use since it is cheap and since we faithfully become good testosterone levels in nearly everybody. The drawback is that a person needs to come in every few weeks to get a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to research. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical treatments help maintain a more uniform amount of blood testosterone. The first kind of topical therapy has been 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 limits its usage.
The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. Based on my experience, it tends to be absorbed to good degrees in about 80% to 85 percent of men, but that leaves a substantial number who don't absorb enough for this to have a positive effect. [For details on various formulations, see table ]
Are there any drawbacks to using dyes? How much time does it take for them to work?
Men who begin using the implants need to return in to have their testosterone levels measured again to make sure they are absorbing the right amount. Our target is that the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just several doses. I normally measure it after two weeks, even although symptoms may not change for a month or two.