Programs In hrt - An Analysis

A Harvard expert shares his thoughts on testosterone-replacement therapy

It might be said that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, big muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" which makes testosterone gradually becomes less effective, and testosterone levels start to fall, by approximately 1% a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like lower libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with just about 5 percent of these affected receiving treatment.

Various studies have revealed that testosterone-replacement therapy can offer a vast selection of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production.

He has developed particular expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his own patients, and he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What signs and symptoms of low testosterone prompt the average man to see a doctor?

As a urologist, I have a tendency to see men because they have sexual complaints. The main hallmark of reduced testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a much smaller quantity of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something which would usually be arousing.

The more of these symptoms you will find, the more probable it is that a man has low testosterone. Many physicians tend to discount those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by decreasing testosterone levels.

Aren't those the same symptoms that men have when they are treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are quite a few drugs that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the amount of the ejaculatory fluid, no wonder. But a decrease in orgasm intensity usually doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it either, though surely if a person has less sex drive or less attention, it's more of a struggle to have a fantastic erection.

How can you determine whether or not a person is a candidate for testosterone-replacement treatment?

There are just two ways we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between these two approaches is far from ideal. Normally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. However, there are some men who have low 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 entire testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. But no one really agrees on a few. It is not like diabetes, where if your fasting sugar is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should here are the findings and shouldn't receive testosterone look here therapy. Watch"Endocrine Society recommendations summarized."

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

Well, this is another area of confusion and great discussion, 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 body. But about half of the testosterone that's circulating in the bloodstream is not available to the cells.

The biologically available portion of overall testosterone is called free testosterone, and it is readily available to the cells. Almost every lab has a blood test to measure free testosterone. Even though it's only a small portion of the total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the significance is greater than with testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have both

Therapy is not recommended for men who've

Prostate or breast cancer
a nodule on the prostate that may be felt during a DRE
that a PSA higher than 3 ng/ml without further evaluation
a hematocrit greater than 50% or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract infections

class III or IV visit this site right here heart failure.

Do time daily, diet, or other factors influence testosterone levels?

For many years, the recommendation has been to get a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. However, the information behind that recommendation were attracted to healthy young men. Two recent studies demonstrated little change in blood glucose levels in men 40 and mature within the course of the day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a modest sum, and probably insufficient to influence diagnosis. Most guidelines still say it's important to do the test in the morning, however for men 40 and over, it likely does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.

There are some very interesting findings about diet. For example, it appears that individuals who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied thoroughly enough to make any recommendations that are clear.

Exogenous vs. endogenous testosterone

In the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Based on the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.

Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the creation of natural testosterone, termed endogenous testosterone, in men. Within four to six weeks, each one the men had increased levels of testosterone; none reported some side effects during the year they had been followed.

Because clomiphene citrate is not approved by the FDA for use in males, little information exists regarding the long-term effects of taking it (including the probability of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone who wish to father children.

Formulations

What kinds of testosterone-replacement therapy are available? *

The earliest form is an injection, which we use because it is inexpensive and since we reliably get fantastic testosterone levels in nearly everybody. The disadvantage is that a man needs to come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline. [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 one study, as many as 40% of men who used the patch developed a reddish area on their skin. That limits its usage.

The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. According to my experience, it has a tendency to be absorbed to good degrees in about 80% to 85 percent of guys, but that leaves a substantial number who do not consume enough for this to have a favorable effect. [For details on several different formulations, see table ]

Are there any drawbacks to using gels? How long does it take for them to get the job done?

Men who begin using the implants need to come back in to have their own testosterone levels measured again to be sure they're absorbing the right amount. Our target is the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just several doses. I normally measure it after 2 weeks, even although symptoms may not change for a month or two.

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