A Harvard expert shares his Ideas on testosterone-replacement Treatment
A meeting 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, large muscles, and facial and body 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 production of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" that makes testosterone slowly becomes less effective, 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 might begin to have signs and symptoms of low testosterone like reduced 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" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5 percent of these affected undergoing therapy.
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 sexual and reproductive difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and he believes experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the average person to find a doctor?
As a urologist, I tend to see men since they have sexual complaints. The primary hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and some other guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.
The more of the 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 are often treatable and reversible by normalizing 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 quite a few drugs that may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though surely if somebody has less sex drive or less attention, it is more of a challenge to have 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 is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are some guys who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. However, no one really agrees on a number. It's not like diabetes, in which if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. See"Endocrine Society recommendations click this site summarized." For a complete copy of these guidelines, log on to www.endo-society.org. |
Is complete testosterone the right thing to be measuring? Or should we be measuring something different?
This is another area of confusion and good debate, but I don't think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the human body. However, about half of the testosterone that's circulating in the blood 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 part of total testosterone is called free testosterone, and it's readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's just a small fraction of this overall, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater compared to total testosterone.
Endocrine Society recommendations outlinedThis professional organization urges testosterone therapy for men who have
Therapy Isn't Suggested for men who have
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