A meeting with Abraham Morgentaler, M.D.
It might be said that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, 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 aids cognition.
Over time, the "machinery" which makes testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1% a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone like lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Yet it's an underdiagnosed problem, with just about 5% of these affected undergoing therapy.
Studies have revealed that testosterone-replacement therapy may provide a vast range of advantages for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production.
He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his patients, and why he believes specialists should rethink the possible connection between testosterone-replacement treatment and prostate cancer.Symptoms and diagnosis
What signs and symptoms of low testosterone prompt the typical person to find a doctor?
As a urologist, I tend to observe men 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 must get his testosterone level checked. Men can experience different symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of ejaculation, and a sense of numbness in the penis when they see or experience something which would usually be arousing.
The more of these symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few drugs that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not usually go together with it , though certainly if a person has less sex drive or less attention, it is more of a challenge to get a good erection.
How do you decide if or not a person is a candidate for testosterone-replacement therapy?
There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from ideal. Normally guys with the lowest testosterone have the most symptoms and guys with highest 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 for a entire testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one really agrees on a few. It's not like diabetes, where if your fasting glucose is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.
|*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. Watch"Endocrine Society recommendations summarized."|
Is total testosterone the right thing to be measuring? Or should we be measuring something else?
Well, this is another area of confusion and good discussion, but I do not think that 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 the testosterone in the body. But about half of the testosterone that's circulating in the bloodstream is not readily available to cells.
The biologically available part of overall testosterone is known as free testosterone, and it is readily available to cells. Though it's just a little portion of the total, the free testosterone level is a pretty good indicator of reduced testosterone. It is not ideal, but the significance is greater compared to total testosterone.
This professional organization urges testosterone therapy for men who have both
- Low levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not Suggested for men who've
- Breast or prostate cancer
- a nodule on the prostate that can be felt during a DRE
- that a PSA higher than 3 ng/ml without further evaluation
- a hematocrit greater than 50 percent or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract infections
- class III or IV louisville testosterone therapy clinic heart failure. pop over to this web-site
Do time daily, diet, or other elements affect testosterone levels?
For years, the recommendation was to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. However, the information behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and mature over the course of the day. One reported no change in average testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably not enough to influence identification. Most guidelines still say it is important to perform the test in the morning, however for men 40 and over, it probably does not matter much, as long as they get their blood drawn before 5 or 6 p.m.
There are a number of very interesting findings about diet. By way of example, it seems that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been researched thoroughly enough to make any recommendations that are clear.
Exogenous vs. endogenous testosterone
Within this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Depending upon the formula, 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.
Within four to six weeks, each one of the guys had heightened levels of testosterone; none reported some side effects during the entire year they were followed.
Because clomiphene citrate isn't approved by the FDA for use in males, little information exists about the long-term effects of carrying it (including the probability of developing prostate cancer) or whether it is more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enriches -- sperm production. This makes medication such as clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.
What kinds of testosterone-replacement treatment can be found? *
The earliest form is an injection, which we still use because it's cheap and since we reliably become good testosterone levels in nearly everybody. The drawback is that a person should come in every few weeks to find a shot. A roller-coaster effect can also happen as blood testosterone levels peak and then return to baseline. [See"Exogenous vs. endogenous testosterone," above.]
Topical therapies help preserve a more uniform amount of blood testosterone. The first kind of topical treatment was a patch, but it has a very large rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a reddish area in their skin. That limits its use.
The most widely used testosterone preparation in the United States -- and the one I start almost everyone off -- is a topical gel. The gel comes in miniature tubes or in a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it tends to be consumed to great levels in about 80% to 85 percent of guys, but leaves a substantial number who do not consume enough for this to have a positive effect. [For specifics on various formulations, see table below.]
Are there any downsides to using dyes? How long does it require them to get the job done?
Men who start using the implants need to come back in to have their testosterone levels measured again to be certain they are absorbing the right quantity. Our goal is that the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, in just several doses. I usually measure it after 2 weeks, even though symptoms may not change for a month or two.