It could be said that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. Additionally, it boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" which produces testosterone slowly becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent per year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these symptoms and signs are often referred to as 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 USA. Yet it's an underdiagnosed issue, with just about 5% of those affected receiving treatment.
Various studies have shown that testosterone-replacement therapy may offer a vast selection of advantages for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production.
He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and why he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.Symptoms and diagnosis
What signs and symptoms of low testosterone prompt the typical man to see a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, 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 normally be arousing.
The more of the symptoms there are, the more likely 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 drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go together with it either, though surely if somebody has less sex drive or less interest, it is more of a challenge to have a good erection.
How do you decide whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that's a sensible guide. But no one really agrees on a few. It's similar to 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 apparent.
|*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone click for more info treatment. See"Endocrine Society recommendations summarized." For a complete copy of click to read more these guidelines, get more log on to www.endo-society.org.
Is complete testosterone the ideal thing to be measuring? Or if we are measuring something different?
This is another area of confusion and great discussion, 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 learned about overall testosterone, or all of the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't available to the 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 total testosterone is known as free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Though it's only a small fraction of this overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with testosterone.
Do time of day, diet, or other factors affect testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind this recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within the course of the day. One reported no change in average testosterone until after 2 p.m. Between 2 and 6 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines nevertheless say it is important to perform the evaluation in the morning, but for men 40 and above, it probably doesn't matter much, provided that they obtain their blood drawn before 6 or 5 p.m.
There are a number of very interesting findings about diet. For example, it appears that individuals who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been researched thoroughly enough to make any clear recommendations.
Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Depending on the formulation, 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, may boost the production of natural testosterone, known as endogenous testosterone, in men. In a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six months, all of the men had heightened levels of testosteronenone reported any side effects during the entire year they were followed.
Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of carrying it (such as the risk of developing prostate cancer) or if it is more capable of boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes medication like clomiphene citrate one of just a few choices for men with low testosterone that want to father children.
What kinds of testosterone-replacement therapy are available? *
The earliest form is an injection, which we use because it is inexpensive and since we reliably become good testosterone levels in almost everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and return to research.
Topical treatments help maintain a more uniform amount of blood testosterone. The first form of topical treatment was a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a reddish area on their skin. That restricts its use.
The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. Based on my experience, it tends to be consumed to good degrees in about 80% to 85 percent of men, but that leaves a significant number who don't consume sufficient for it to have a positive impact. [For specifics on various formulations, see table ]
Are there any downsides to using dyes? How long does it take for them to get the job done?
Men who begin using the gels have to come back in to have their own testosterone levels measured again to be sure they're absorbing the proper quantity. Our target is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite fast, in just a few doses. I normally measure it after two weeks, although symptoms may not alter for a month or two.