Real-World trt Programs For 2012

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

It could be said that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from women. 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.

As time passes, the "machinery" which makes testosterone slowly becomes less effective, and testosterone levels begin to fall, by approximately 1 percent per year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like reduced libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms 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 United States. Yet it is an underdiagnosed problem, with just about 5 percent of those affected receiving treatment.

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 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 sexual and reproductive difficulties. He's developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his patients, and he thinks experts should reconsider the potential link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see guys because they have sexual complaints. The main hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and some other man who complains of erectile dysfunction should possess his testosterone level checked. Men may experience other symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a smaller quantity of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something which would usually be arousing.

The more of the symptoms there are, the more likely it is that a man has low testosterone. Many physicians often discount these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.

Aren't those the same symptoms that guys 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 can also reduce the quantity of the ejaculatory fluid, no wonder. 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's more of a challenge to have a fantastic erection.

How can you decide whether a person is a candidate for testosterone-replacement treatment?

There are two ways that we determine whether someone has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are some guys who have reduced levels of testosterone in their blood and have no signs.

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 is a sensible guide. However, no one really agrees on a number. It's similar to diabetes, in which if your fasting sugar is over 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 recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. For a complete copy my link of the guidelines, log on to www.endo-society.org. over here

Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?

This is just another area of confusion and good debate, but I don't think it's as confusing as it appears to be from the literature. When most doctors learned about testosterone in medical school, they learned about overall 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 the cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of total testosterone is known as free testosterone, and it is readily available to the cells. Even though it's only a small fraction of the total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater compared to total testosterone.

Endocrine Society recommendations outlined

This professional organization recommends testosterone therapy for men who have both

Therapy Isn't Suggested for men who have

  • 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 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure.

Do time of day, diet, or other elements influence testosterone levels?

For years, the recommendation has been to receive a testosterone value early in the morning since levels start to drop after 10 or even 11 a.m.. But the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older over the course of this day. One reported no change in average testosterone until after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to affect identification. Most guidelines still say it is important to perform the evaluation in the morning, however for men 40 and over, it likely doesn't matter much, provided that they obtain 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 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 make any clear recommendations.

Exogenous vs. endogenous testosterone

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

Within four to six months, each one of the men had increased levels of testosterone; none reported some side effects throughout the year they had been followed.

Since clomiphene citrate is not accepted by the FDA for use in men, little information exists about the long-term ramifications of carrying it (including the probability of developing prostate cancer) or whether it's more capable of boosting testosterone than exogenous formulas. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes medication such as clomiphene citrate one of only a few choices for men with low testosterone that wish to father children.

Formulations

What kinds of testosterone-replacement treatment are available? *

The oldest form is an injection, which we use because it is inexpensive and because we reliably become fantastic testosterone levels in nearly everybody. The disadvantage is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to research. [See"Exogenous vs. endogenous testosterone," above.]

Topical therapies help maintain a more uniform amount of blood glucose. The first kind of topical therapy 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 red area on their skin. That restricts its usage.

The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off with -- is a topical gel. Based on my experience, it tends to be absorbed to great degrees in about 80% to 85 percent of guys, but that leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For specifics on various formulations, see table below.]

Are there any drawbacks to using gels? How long does it take for them to work?

Men who start using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper quantity. Our goal is that the mid to upper assortment of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, in just 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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