Sensible Advice For trt In The Uk

A Harvard expert shares his thoughts on testosterone-replacement therapy

An interview with Abraham Morgentaler, M.D.

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

Over time, the "machinery" which makes testosterone slowly becomes less powerful, and testosterone levels start to drop, by approximately 1% per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have symptoms and signs of low testosterone such as lower libido and sense of vitality, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low working 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 problem, with just about 5% of these affected receiving treatment.

Much of the current debate focuses on the long-held belief that testosterone may 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 ailments and male sexual and reproductive problems. 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 utilizes his own patients, and he thinks experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt the typical person to see a physician?

As a urologist, I have a tendency to see guys because they have sexual complaints. The main hallmark of reduced 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 may experience different symptoms, such as more difficulty achieving an orgasm, less-intense climaxes, a smaller quantity 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 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.

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

Not exactly. There are quite a few drugs which may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no question. But a reduction in orgasm intensity normally doesn't go together with therapy for BPH. Erectile dysfunction does not usually go along with it either, though surely 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 somebody has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two approaches is far from perfect. Generally men with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. However, 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* believes 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 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 clear.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive discover here testosterone therapy. For a complete copy of Recommended Reading the guidelines, log on to www.endo-society.org.

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 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 learned about overall testosterone, or all of the testosterone in the body. But about half of the testosterone that's circulating in the bloodstream is not available to cells. It's tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of overall testosterone is known as free testosterone, and it's readily available to the cells. 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 ideal, but the correlation is greater than with total testosterone.

Endocrine Society recommendations summarized

This professional organization urges testosterone treatment 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 have

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

Do time daily, diet, or other elements affect testosterone levels?

For many years, the recommendation was to get a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. But the information behind this recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of the day. One reported no change in typical testosterone until after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a small amount, and probably insufficient to influence identification. Most guidelines still say it is important to perform the evaluation in the morning, however for men 40 and above, it probably does not matter much, provided that they obtain their blood drawn before 6 or 5 p.m.

There are a number of rather interesting findings about diet. By way of example, it seems that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to create any recommendations that are clear.

In the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based upon the formulation, therapy can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with additional side effects.

Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, known as nitric oxide, in men. Within four to six weeks, all the guys had heightened levels of testosterone; none reported some 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 (such as the risk of developing prostate cancer) or if it's more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone who want to father children.

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

The oldest form is an injection, which we still use since it is cheap and because we reliably get fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also happen as blood glucose levels peak and then return to baseline. [See"Exogenous vs. endogenous testosterone," above.]

Topical treatments help preserve a more uniform level of blood testosterone. 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 red area in their skin. That restricts its usage.

The most widely used testosterone preparation from the United States -- and also the one I begin almost everyone off -- 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. Based on my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but that leaves a substantial number who don't absorb enough for it to have a favorable impact. [For details on several different formulations, see table ]

Are there any drawbacks to using gels? How much time does it require them to get the job done?

Men who begin using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper amount. Our target is 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, within a few doses. I usually measure it after 2 weeks, even although symptoms may not alter for a month or two.

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