Real-World testosterone therapy Programs For 2012

A Harvard expert shares his Ideas on testosterone-replacement Treatment

It could be said that testosterone is what makes guys, men. 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 , plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and aids cognition.

As time passes, the testicular"machinery" which produces testosterone gradually becomes less powerful, and testosterone levels begin to drop, by approximately 1 percent per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone like reduced libido and sense of energy, erectile dysfunction, diminished energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low functioning 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 issue, with only about 5 percent of those affected receiving treatment.

Various studies have revealed that testosterone-replacement therapy may offer a wide range of advantages for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on 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.

He has developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he uses with his own patients, and why he believes specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see guys since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another can be erectile dysfunction, and some other man who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a smaller quantity of fluid from ejaculation, and a sense of numbness in the manhood when they see or experience something which 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 discount these"soft symptoms" as a normal part of aging, but they're 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 exactly. There are a number of medications that may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no wonder. However a reduction in orgasm intensity usually does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if somebody has less sex drive or less interest, it's more of a struggle to get a fantastic erection.

How can you determine if or not a man 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 methods is far from ideal. Generally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. However, there are some guys who have low levels of testosterone in their blood and have no symptoms.

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 reasonable guide. However, no one really agrees on a number. It's not like diabetes, where if your fasting sugar is above a certain level, they'll 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 great post to read for who should and should not find out this here receive testosterone treatment.

Is complete testosterone the right thing to be measuring? Or should we be measuring something else?

This is 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 physicians learned about testosterone in medical school, they heard about overall testosterone, or all the testosterone in the body. However, about half of the testosterone that's circulating in the blood is not readily available to cells. It is tightly bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The available part of total testosterone is called free testosterone, and it's 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 this overall, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the correlation is greater than with total testosterone.

This professional organization recommends testosterone treatment for men who have

Low levels of testosterone in the blood (less than 300 ng/dl)
symptoms of low testosterone.

Therapy Isn't recommended for men who've

Breast or prostate cancer
a nodule on the prostate which may be felt during a DRE
that a PSA greater than 3 ng/ml without further evaluation
that 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 factors influence testosterone levels?

For 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.. However, the information behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in typical testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably insufficient to influence identification. Most guidelines still say it is important to perform the test in the morning, however for men 40 and over, it likely doesn't matter much, as long as they get their blood drawn before 6 or 5 p.m.

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

Exogenous vs. endogenous testosterone

Within the following guide, testosterone-replacement treatment refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending upon the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the production of natural testosterone, also termed nitric oxide, in men. Within four to six months, each one of the guys had heightened levels of testosteronenone reported any side effects throughout the year they had been followed.

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

What kinds of testosterone-replacement therapy are available? *

The earliest form is the injection, which we use since it's inexpensive and since we faithfully become fantastic testosterone levels in nearly everybody. The disadvantage is that a person should come in every few weeks to get a shot. A roller-coaster effect can also happen as blood glucose levels peak and then return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical therapies help maintain a more uniform amount of blood testosterone. The first kind 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 on their skin. That restricts its use.

The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. The gel comes from miniature tubes or within a special 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 degrees in about 80% to 85 percent of guys, but leaves a substantial number who do not consume sufficient for it to have a favorable effect. [For specifics on several different formulations, see table ]

Are there any downsides to using gels? How long does it require them to get the job done?

Men who begin using the gels have to come back in to have their testosterone levels measured again to be certain they are absorbing the right amount. Our goal is that the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite quickly, within several doses. I normally measure it after two weeks, although symptoms may not alter for a month or two.

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