Aspects For trt - What's Required

A Harvard Specialist shares his Ideas on testosterone-replacement therapy

It might be stated that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids 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 in their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone such as reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased 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's an underdiagnosed issue, with just about 5% of those 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 can stimulate prostate cancer.

He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his patients, and he believes specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see men because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally be arousing.

The more of the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.

Aren't those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few drugs which may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity usually does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it either, though certainly if somebody has less sex drive or less interest, it is more of a challenge to have a fantastic erection.

How can you determine if a person is a candidate for testosterone-replacement therapy?

There are two ways we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between these two methods is far from perfect. Normally men with the lowest testosterone have the most symptoms and guys 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 believe that is a sensible guide. But no one really agrees on a number. It's similar to diabetes, in which 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 publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. For a complete copy of his comment is here the guidelines, log on to explanation www.endo-society.org.

Is complete testosterone the ideal thing to be measuring? Or should we be measuring something different?

This is just another area of confusion and great debate, but I do not think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the human body. However, about half of the testosterone that's circulating in the bloodstream isn't readily available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available portion of overall testosterone is known as free testosterone, and it's readily available to the cells. Almost every laboratory has a blood test to measure free testosterone. Though it's only 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 than with total testosterone.

This professional organization recommends testosterone therapy for men who have both

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

Therapy Isn't Suggested for men who've

Prostate or breast cancer
a nodule on the prostate that can be felt during a DRE
a PSA greater than 3 ng/ml without further evaluation
a hematocrit greater than 50% or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract infections

class III or IV useful content heart failure.

Do time of day, diet, or other factors affect testosterone levels?

For years, the recommendation has been to get a testosterone value early in the morning since levels begin to fall after 10 or even 11 a.m.. However, the information behind that recommendation were attracted to 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 typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect diagnosis. Most guidelines nevertheless say it is important to perform the evaluation in the morning, however for men 40 and over, it probably doesn't 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 dietary supplements. For example, it appears that those that have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been studied thoroughly enough to create any clear recommendations.

Exogenous vs. endogenous testosterone

Within the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formulation, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.

Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may foster the production of natural testosterone, also known as endogenous testosterone, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, all the guys had heightened levels of testosterone; none reported some side effects during the year they had been followed.

Because clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the probability of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate maintains -- and possibly enriches -- sperm production. That makes medication such as clomiphene citrate one of only a few options 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 still use since it's cheap and since we faithfully get fantastic testosterone levels in nearly everybody. The disadvantage is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and return to baseline.

Topical therapies help preserve a more uniform level of blood testosterone. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a red area in their skin. That limits its use.

The most widely used testosterone preparation in the United States -- and also the one I start almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes in miniature tubes or within a special dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be absorbed to great levels in about 80% to 85% 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 below.]

Are there any downsides to using gels? How long does it require them to get the job done?

Men who start using the implants need to return in to have their testosterone levels measured again to be certain they're absorbing the right quantity. Our goal is the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, in just several doses. I usually measure it after two weeks, even although symptoms may not alter for a month or two.

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