Key Details In testosterone therapy Around The Usa

A Harvard expert shares his Ideas on testosterone-replacement Treatment

It could 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 growth of the genitals , 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 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 such as 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" 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 receiving treatment.

But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.

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 utilizes his own patients, and why he believes specialists should rethink the possible link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt that the typical person to find a doctor?

As a urologist, I tend to see guys since they have sexual complaints. The main hallmark of reduced testosterone is reduced 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 different symptoms, like more trouble achieving an orgasm, less-intense orgasms, a smaller amount of fluid out of ejaculation, and a feeling 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 guys 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 may also reduce 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 along with it either, though surely if a person has less sex drive or less attention, it is more of a challenge to get a good erection.

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

There are two ways we determine whether somebody has low 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. However, there are some men who have reduced levels of testosterone in their blood and have no signs.

Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. See"Endocrine Society recommendations summarized." For a complete copy of view website the instructions, log on to www.endo-society.org.

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

This is another area of confusion and good debate, but I don't think that 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 of the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream is not available to cells. It's closely bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Though it's only a little fraction 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 which can be felt during a DRE
  • that 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 factors affect testosterone levels?

For many years, the recommendation has been to get a testosterone value early in the morning since levels start to fall 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 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%, a modest sum, and probably not enough to affect identification. Most guidelines still say it's important to perform the evaluation in the morning, but for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

There are a number of rather interesting findings about diet. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to make any recommendations that are clear.

Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based upon the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects.

At 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 guys had heightened levels of testosterone; none reported any side effects during the year they were followed.

Because clomiphene citrate is not approved by the FDA for use in males, little information exists regarding the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it's more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of just a few options for men with low testosterone who wish to father children.

What forms of testosterone-replacement therapy are available? *

The earliest form is the injection, which we use because it's cheap and since we reliably get good testosterone levels in almost everybody. The drawback is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to baseline.

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

The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. The gel comes in miniature tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it has a tendency to be consumed to good degrees in about 80% to 85 percent of men, but that leaves a significant number who do not absorb sufficient for it to have a positive impact. [For specifics on several different formulations, see table ]

Are there any downsides to using dyes? How long does it require them to work?

Men who begin using the implants need to come back in to have their own testosterone levels measured again to make certain they are absorbing the right quantity. 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 actually goes up quite fast, within several doses. I normally measure it after two weeks, even though symptoms may not alter for a month or two.

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