A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
An interview 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, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular"machinery" that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may 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 anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed issue, with just about 5 percent of these affected undergoing therapy.
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 diseases and male sexual and reproductive difficulties. He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he utilizes his own patients, and why he thinks experts should reconsider the possible link between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the average man to find a physician?
As a urologist, I have a tendency to see men since they have sexual complaints. The main hallmark of reduced 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 other symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a much smaller amount of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.
The more of the 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're often treatable and reversible by normalizing testosterone levels.
Aren't 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 which may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a decrease in orgasm intensity usually doesn't go along with therapy for BPH. Erectile dysfunction does not usually go along with it , though surely if somebody has less sex drive or less attention, it's more of a challenge to have a good erection.
How can you determine whether or not a man is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. However, there are some guys who have low levels of testosterone in their blood and have no signs.
Looking purely at the biochemical numbers, 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 number. It's similar to diabetes, where if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
| *Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone check my source treatment. For a complete copy this page of these guidelines, log on to www.endo-society.org. published here Is total testosterone the ideal thing to be measuring? Or if we are measuring something different? Well, this is just another area of confusion and good debate, but I don't think it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. But about half of the testosterone that's circulating in the blood isn't available to the cells. 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 just a little fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the correlation is greater than with total testosterone.
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