A Harvard expert shares his Ideas on testosterone-replacement therapy
It could be said that testosterone is what makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing 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 production of red blood cells, boosts mood, and aids cognition.
As time passes, the "machinery" that produces testosterone gradually becomes less effective, and testosterone levels start to drop, by about 1% per year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone like reduced libido and sense of vitality, 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 functioning and"gonadism" speaking to the testicles). Researchers estimate that the illness affects anywhere from two to six million men in the USA. Yet it is an underdiagnosed problem, with only about 5% of those affected undergoing therapy.
Various studies have shown that testosterone-replacement therapy can provide a vast selection of advantages for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production.
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 difficulties. He has developed particular expertise 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 he believes specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt that the typical man to find a doctor?
As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a lesser quantity of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something which would normally be arousing.
The more of the symptoms there are, 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're often treatable and reversible by decreasing testosterone levels.
Aren't those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few drugs that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if a person has less sex drive or less attention, it's more of a challenge to get a good erection.
How can you determine if a person is a candidate for testosterone-replacement therapy?
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 methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no symptoms.
Looking purely 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 is a sensible guide. However, no one really agrees on a number. It is not like diabetes, where if your fasting glucose is above a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations summarized." Is total testosterone the right thing to be measuring? Or if we are measuring something different? This is just another area of confusion and good debate, but I don't think it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. However, about half of the testosterone that is circulating in the blood is not readily available to the cells. The biologically available portion of total testosterone is known as free testosterone, and it is readily available to cells. Even though it's only a little fraction of the total, the free testosterone level is a pretty good indicator of low testosterone. It is not perfect, but the correlation is greater than with testosterone.
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