A Harvard expert shares his thoughts on testosterone-replacement Treatment
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and contributes to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and aids cognition.
As time passes, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to drop, by approximately 1 percent per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, diminished energy, decreased 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" speaking to the testicles). Yet it is an underdiagnosed problem, with only about 5% of those affected undergoing therapy.
But little consensus exists about 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.
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 experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and he thinks specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average person to find a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should possess his testosterone level checked. Men can experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something which 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 those"soft symptoms" as a normal part of aging, however, they're 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 drugs that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if somebody has less sex drive or less attention, it's more of a struggle to get a fantastic erection.
How do you determine if or not a person is a candidate for testosterone-replacement therapy?
There are two ways that we determine whether somebody 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. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone possess the least. But there are a number of guys who have low levels of testosterone in their blood and have no symptoms.
Looking purely at the biochemical amounts, The Endocrine Society* considers low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible 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'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. Watch"Endocrine Society recommendations summarized." Is complete testosterone the ideal point to be measuring? Or if we are measuring something else? Well, this is just another area of confusion and good discussion, but I don't think that it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the body. But about half of the testosterone that is circulating in the bloodstream is not available to cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available part of overall testosterone is known as free testosterone, and it is readily available to cells. Even though it's only a little portion of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with testosterone.
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