A meeting with Abraham Morgentaler, M.D.
It might 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 development of the genitals , plays a role in sperm production, fuels libido, and leads to normal 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% per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as lower libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" meaning low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of those 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 problems. He has developed specific expertise 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 why he believes experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.Symptoms and diagnosis
What signs and symptoms of low testosterone prompt the average person to see a physician?
As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other 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 lesser amount of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would usually be arousing.
The more of these symptoms there are, the more probable 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 normalizing testosterone levels.
Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are a number of medications which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. 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 surely if a person has less sex drive or less attention, it is more of a challenge to get a fantastic erection.
How do you determine if a person is a candidate for testosterone-replacement treatment?
There are just 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 these two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.
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 believe that's a reasonable guide. But no one really agrees on a number. It is not like diabetes, where if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
|*Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. Watch"Endocrine Society click resources recommendations summarized."
Is complete testosterone the right thing to be measuring? Or if we are measuring something different?
Well, this is another area of confusion and great debate, but I do not think it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream isn't readily available to the cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.
The available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Nearly every laboratory has a blood test to measure free testosterone. Even though it's just a little portion of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the correlation is greater than with testosterone.
What forms of testosterone-replacement treatment can be found? *
The oldest form is an injection, which we use since it is cheap and because we faithfully get good testosterone levels in nearly everybody. The disadvantage is that a person should come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to research. [Watch"Exogenous vs. endogenous testosterone," above.]
Topical therapies help preserve a more uniform level of blood glucose. The first form of topical therapy has been a patch, but it has a quite large rate of skin irritation. In 1 study, as many as 40% of people that used the patch developed a reddish area on their skin. That restricts its use.
The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes from miniature tubes or within a unique 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 good levels in about 80% to 85 percent of guys, but leaves a substantial number who do not consume enough for it to have a favorable impact. [For specifics on several different formulations, see table below.]
Are there any downsides to using gels? How much time does it require them to get the job done?
Men who start using the implants need to come back in to have their testosterone levels measured again to make sure they're absorbing the right quantity. Our goal is that the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just a few doses. I usually measure it after two weeks, even though symptoms may not alter for a month or two.