Vital Factors For trt In The Uk

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

 

A meeting with Abraham Morgentaler, M.D.

It could be said that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating 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 boosts the production of red blood cells, boosts mood, and aids cognition.

As time passes, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as lower sex drive and sense of vitality, 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" referring 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 percent of those 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 problems. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and 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 that the average person to see a physician?

As a urologist, I have a tendency to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a lesser amount of fluid out of ejaculation, and a feeling of numbness in the manhood 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 discount these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.

Are not those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of drugs that may reduce libido, 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 decrease in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if a person has less sex drive or less interest, it's more of a struggle to get a good erection.

How do you determine if or not a man 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 approaches is far from ideal. Normally men with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. But there are a number of guys who have reduced levels of testosterone in their blood and have no symptoms.

Looking at the biochemical numbers, The Endocrine Society* considers low testosterone for a total testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one really agrees on a few. It is similar to 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.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for her explanation who should and should not Get More Information receive testosterone therapy. See"Endocrine Society recommendations summarized."

Is total testosterone the ideal point to be measuring? Or if we are measuring something different?

This is just 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 physicians learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the body. But about half of their testosterone that is circulating in the bloodstream isn't readily available to cells.

The available portion 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. Though it's only a small portion of this total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not perfect, but the correlation is greater compared to total testosterone.

This professional organization recommends testosterone treatment for men who have

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

Therapy Isn't recommended for men who have

  • Prostate or breast cancer
  • a nodule on the prostate which can be felt during a DRE
  • a PSA higher than 3 ng/ml without additional evaluation
  • that a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure.

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

    For years, the recommendation has been to receive a testosterone value early in the morning because levels start to fall after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of this day. One reported no change in typical testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably not enough to influence diagnosis. Most guidelines nevertheless say it's important to perform the test in the morning, however for men 40 and over, it probably does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

    There are a number of very interesting findings about dietary supplements. For 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.

    Within this guide, testosterone-replacement therapy 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.

    At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all of the guys had heightened levels of testosteronenone reported any side effects throughout the year they had been followed.

    Since clomiphene citrate is not approved by the FDA for use in males, little information exists about the long-term effects of carrying it (including the risk of developing prostate cancer) or if it's more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes medication such as clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.

Formulations

What forms of testosterone-replacement treatment can be found? *

The earliest form is an injection, which we still use since it is inexpensive and since we reliably become fantastic testosterone levels in almost everybody. The drawback is that a person needs to come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood testosterone levels peak and then return to baseline.

Topical treatments help maintain a more uniform level of blood testosterone. The first kind of topical therapy was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40 percent of people that used the patch developed a reddish area in their skin. That limits its use.

The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. There are just two brands: AndroGel and Testim. The gel comes from tiny tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be absorbed to good degrees in about 80% to 85% of men, but leaves a significant number who do not consume enough for it to have a positive effect. [For specifics on various formulations, see table ]

Are there any downsides to using gels? How much time does it require them to work?

Men who begin using the implants need to return in to have their own testosterone levels measured again to be sure they're absorbing the right amount. 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 the blood actually goes up quite quickly, in just several doses. I usually measure it after two weeks, though symptoms may not alter for a month or two.

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