No-Hassle Methods Of trt Described

A Harvard Specialist shares his Ideas on testosterone-replacement Treatment

An interview with Abraham Morgentaler, M.D.

It might be said that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.

Over time, the "machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a 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 energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" speaking 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 percent of these affected receiving treatment.

But little consensus exists about 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 has developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his patients, and he thinks experts should reconsider the potential connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see men since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as 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 men have when they're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of drugs that may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go along with it , though certainly if somebody has less sex drive or less attention, it is more of a struggle to get a fantastic erection.

How can you decide if a man is a candidate for testosterone-replacement therapy?

There are just two ways we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two approaches is far from ideal. Generally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are a number of guys who have low levels of testosterone in their blood and have no symptoms.

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. However, no one really agrees on a number. It is similar to diabetes, where if your fasting sugar is over 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 therapy. For a complete copy of these guidelines, log on to www.endo-society.org.

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

Well, this is just another area of confusion and good debate, but I do not think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream is not readily available to the cells.

The biologically 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. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with total testosterone.

This professional organization urges testosterone therapy for men who have

  • Reduced levels of testosterone in the blood (less than 300 ng/dl)
  • symptoms of low testosterone.

Therapy is not Suggested for men who have

  • Breast or prostate cancer
  • a nodule on the prostate that can be felt during a DRE
  • that a PSA greater than 3 ng/ml without additional evaluation
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class useful source III or IV heart failure.

    Do time daily, diet, or other factors 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 data behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and older within the course of this day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest amount, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it is important to do the evaluation in the morning, however for men 40 and above, 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 example, it appears that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet hasn't been researched 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.

    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 men, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who want to father children.

    Formulations

    What forms of testosterone-replacement therapy are available? *

    The oldest form is the injection, which we use because it's inexpensive and because we faithfully become fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline. [See"Exogenous vs. endogenous testosterone," above.]

    Topical therapies help preserve a more uniform amount of blood testosterone. The first form of topical therapy has been a patch, but it has a very high rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area on their skin. That restricts its usage.

    The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be consumed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb sufficient for this to have a positive impact. [For details on various formulations, see table ]

    Are there any drawbacks to using dyes? How much time 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 amount. Our target is that the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite quickly, in just a few doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.

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