Picking Out Effective Methods For trt

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

 

 

It could be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and body and facial hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.

As time passes, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by approximately 1% a 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 such as reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Yet it's an underdiagnosed problem, with just about 5% of those affected undergoing therapy.

Studies have revealed that testosterone-replacement therapy may provide a wide range of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. Much of the current debate focuses on the long-held belief that testosterone can 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 sexual and reproductive problems. He's developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he thinks experts should reconsider the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to observe men since they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of 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 you will find, the more probable it is that a man has low testosterone. Many physicians often dismiss those"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 men have when they're treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are quite a few medications that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go along with it either, though surely if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.

How can you determine if or not a person is a candidate for testosterone-replacement therapy?

There are just two ways 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 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 low levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, 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 is not quite as clear.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone click here for more info treatment. For a complete copy of the Recommended Site guidelines, log on to www.endo-society.org.

Is total testosterone the right thing to be measuring? Or should we be measuring something else?

Well, this is another area of confusion and great debate, but I don't think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all the testosterone in the body. But about half of the testosterone that's circulating in the blood isn't readily available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available part of total testosterone is called free testosterone, and it is readily available to cells. Though it's just a little portion of this overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone therapy for men who have

Therapy Isn't recommended for men who have

  • Prostate or breast cancer
  • a nodule on the prostate which may be felt during a DRE
  • a PSA greater than 3 ng/ml without additional analysis
  • a hematocrit greater than 50 percent 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 receive a testosterone value early in the morning since levels start to drop 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 the day. One reported no change in average testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably not enough to affect diagnosis. Most guidelines still say it is important to do the evaluation in the morning, but for men 40 and over, it likely doesn't matter much, provided that they get their blood drawn before 6 or 5 p.m.

    There are some rather interesting findings about diet. By way of instance, it appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been studied thoroughly enough to create any recommendations that are clear.

    Exogenous vs. endogenous testosterone

    In the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that is produced outside the body. Depending upon the formulation, treatment can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and additional side effects.

    In 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 throughout the entire year they had been 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's more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone that wish to father children.

    Formulations

    What kinds of testosterone-replacement therapy are available? *

    The earliest form is the injection, which we still use because it is cheap and because we faithfully become good testosterone levels in almost everybody. The drawback is that a man should come in every few weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to baseline.

    Topical treatments help preserve a more uniform level of blood testosterone. The first kind of topical treatment was a patch, but it has a very high rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area on their skin. That limits its usage.

    The most widely used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For details on several different formulations, see table ]

    Are there any drawbacks to using dyes? How much time does it require them to get the job done?

    Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper quantity. Our target is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, in just a few doses. I usually measure it after two weeks, though symptoms may not change for a month or two.

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