A Harvard expert shares his thoughts on testosterone-replacement Treatment
An interview with Abraham Morgentaler, M.D.
It might be stated that testosterone is what makes men, guys. It gives them their characteristic deep voices, big muscles, and body and facial hair, distinguishing them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it boosts the creation of red blood cells, boosts mood, and aids cognition.
Over time, the "machinery" that produces testosterone gradually becomes less powerful, and testosterone levels begin to fall, by about 1 percent per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they may 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 symptoms and signs are often called hypogonadism ("hypo" significance low functioning and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with just about 5 percent of these affected undergoing therapy.
But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what dangers patients face. 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 reproductive and sexual difficulties. He's developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his patients, and he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt that the average person to see a physician?
As a urologist, I have a tendency to see men because they have sexual complaints. The primary hallmark of low testosterone is reduced sexual libido or desire, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction must get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.
The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.
Aren't those the same symptoms that men have when they're treated for benign prostatic hyperplasia, or BPH?
Not exactly. There are quite a few medications which may reduce libido, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though certainly if a person has less sex drive or less attention, it is more of a struggle to get a good erection.
How do you determine whether or not a person is a candidate for testosterone-replacement treatment?
There are just two ways we determine whether someone has reduced 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 ideal. Normally men with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are a number of men who have low 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 is a sensible guide. However, no one quite agrees on a number. It is similar to 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.
| *Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy. Is total testosterone the ideal thing to be measuring? Or if we are measuring something different? Well, this is another area of confusion and good debate, but I don't think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the body. But about half of their testosterone that's circulating in the blood isn't available to cells. It is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG. The biologically available portion of total testosterone is called free testosterone, and it is readily available to the cells. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not perfect, but the significance is greater than with total testosterone.
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