Considering Rapid Systems In testosterone therapy

A Harvard Specialist shares his thoughts on testosterone-replacement therapy

 

 

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, distinguishing them from women. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. It also boosts 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, starting 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" meaning low working and"gonadism" referring to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of those affected undergoing therapy.

Various studies have shown that testosterone-replacement therapy can offer a vast range of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and he thinks specialists should rethink the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency 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 may experience different symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a lesser quantity of fluid from ejaculation, and a feeling of numbness in the manhood when they see or experience something that would normally be arousing.

The more of the symptoms you will find, 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 precisely. There are a number of medications which may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease 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 ordinarily go together with it , though certainly 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 man is a candidate for testosterone-replacement treatment?

There are just two ways 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 perfect. Generally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are some men who have low levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone for 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 not like 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 recommends clinical practice guidelines with recommendations for who should and should find out here now not receive testosterone treatment. For a complete copy of the guidelines, log on to www.endo-society.org.

Is total testosterone the right thing to be measuring? Or if we are measuring something different?

This is just another area of confusion and good discussion, but I don't think it's as confusing as it appears to be in the literature. When most doctors learned about testosterone in medical school, they heard about overall testosterone, or all of the testosterone in the human body. But about half of the testosterone that's circulating in the bloodstream isn't readily available to cells. It is closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available part of overall testosterone is known as free testosterone, and it is readily available to the cells. Though it's just a small fraction of the overall, the free testosterone level is a fairly good indicator of low testosterone. It's not ideal, but the significance is greater compared to total testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone therapy for men who have

Therapy Isn't Suggested for men who have

  • Prostate or breast cancer
  • a nodule on the prostate which may be felt during a DRE
  • a PSA greater than 3 ng/ml without additional analysis
  • a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV heart look at these guys 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 affect diagnosis. Most guidelines nevertheless say it's important to perform the evaluation in the morning, but for men 40 and over, it probably does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

    There are some rather interesting findings about diet. By way of instance, it appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet hasn't been studied 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 on 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.

    Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the production of natural testosterone, also termed nitric oxide, in men. Within four to six weeks, all the guys had heightened levels of testosteronenone reported some side effects during the entire year they had been followed.

    Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term effects of taking it (such as the risk of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enhances -- sperm production. That makes medication like clomiphene citrate one of only a few options for men with low testosterone that want to father children.

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

    The oldest form is an injection, which we use because it is cheap and because we faithfully become fantastic testosterone levels in nearly everybody. The disadvantage is that a man should come in every couple of 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 treatments help maintain a more uniform level of blood testosterone. The first kind of topical treatment was a patch, but it has a very high 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 widely used testosterone preparation in the United States -- and the one I start almost everyone off with -- is a topical gel. The gel comes in miniature 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 consumed to great degrees in about 80% to 85% of men, but that leaves a substantial number who don't consume sufficient for this to have a favorable impact. [For details on several different formulations, see table ]

    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 make certain they are absorbing the proper amount. Our target is the mid to upper range 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 two weeks, though symptoms may not change for a month or two.

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