A Harvard Specialist shares his thoughts on testosterone-replacement Treatment
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 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 regular erections. It also fosters the creation of red blood cells, boosts mood, and assists cognition.
Over time, the "machinery" which produces testosterone gradually becomes less powerful, and testosterone levels begin to drop, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower sex drive and sense of energy, erectile dysfunction, decreased 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). Researchers estimate that the illness affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed problem, with only about 5 percent of those affected undergoing therapy.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
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 diagnosisWhat 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 since they have sexual complaints. The primary hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction should possess his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally be arousing.
The more of these symptoms you will find, the more likely it is that a man has low testosterone. Many physicians tend to dismiss those"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 which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if a person has less sex drive or less attention, it's more of a challenge to get a fantastic erection.
How can you decide whether a person is a candidate for testosterone-replacement therapy?
There are two ways we determine whether someone 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. Generally guys with the lowest testosterone have the most symptoms and men 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 signs.
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 think that's a reasonable guide. But no one quite agrees on a few. It is similar to diabetes, in which 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 clear.
| *Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. For a complete copy my review here of these instructions, log on to www.endo-society.org. click here to read Is total testosterone the right thing to be measuring? Or should we be measuring something else? This is just another area of confusion and good discussion, but I do not 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 of the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream is not available to cells. It's tightly bound to a carrier molecule called sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available portion of overall testosterone is known as free testosterone, and it's readily available to the cells. Though it's just a small fraction of this overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the significance is greater compared to testosterone.
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