No-Hassle Systems Of testosterone therapy Around The Usa

A Harvard expert shares his Ideas on testosterone-replacement therapy

It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from girls. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.

Over time, the "machinery" which makes testosterone slowly becomes less effective, and testosterone levels begin to fall, by approximately 1 percent per year, starting in the 40s. As men get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone such as reduced sex drive and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Yet it's an underdiagnosed issue, with just about 5% of these affected receiving treatment.

Various studies have shown that testosterone-replacement therapy can offer a vast selection of benefits for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. 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 ailments and male sexual and reproductive difficulties. He has developed specific 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 believes experts should reconsider the possible connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to observe guys because they have sexual complaints. The main hallmark of reduced testosterone is low sexual libido or desire, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more trouble achieving an orgasm, less-intense orgasms, a much smaller amount of fluid out of ejaculation, and a feeling of numbness in the manhood when they see or experience something that would usually be arousing.

The more of the symptoms you will find, the more likely it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.

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

Not exactly. There are quite a few drugs that may lessen sex drive, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the amount of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go along with treatment for BPH. Erectile dysfunction does not ordinarily go together with it either, though certainly if a person has less sex drive or less attention, it's more of a challenge to get a good erection.

How can you determine if a man is a candidate for testosterone-replacement therapy?

There are just two ways we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic symptoms and signs, and the correlation between those two methods is far from ideal. Normally men with the lowest testosterone have the most symptoms and men 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 amounts, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable 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 apparent.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. See"Endocrine Society recommendations summarized." For a check complete copy of these instructions, log on to www.endo-society.org.

Is total testosterone the ideal point to be measuring? Or if we are measuring something different?

This is just another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently from the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all the testosterone in the body. However, about half of their testosterone that's circulating in the bloodstream is not available to cells. It's tightly bound to a carrier molecule called 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 little portion of this total, the free testosterone level is a fairly good indicator of reduced testosterone. It is not ideal, but the significance is greater than with testosterone.

This professional organization urges testosterone therapy for men who have both

Therapy is not recommended for men who've

  • Breast or prostate cancer
  • a nodule on the prostate which can be felt during a DRE
  • a PSA higher than 3 ng/ml without further evaluation
  • a hematocrit greater than 50% or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV heart failure.

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

    For years, the recommendation has been to receive a testosterone value early in the morning since levels start to fall after 10 or 11 a.m.. However, the data 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 this day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably insufficient to influence identification. Most guidelines nevertheless say it is important to do the test in the morning, but for men 40 and over, it likely doesn't matter much, as long as they get their blood drawn before 5 or 6 p.m.

    There are a number of very interesting findings about diet. For example, it appears that those who 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 the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is 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, along with additional side effects.

    Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the production of natural testosterone, also termed endogenous testosterone, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for three or more months. Within four to six weeks, all the guys had increased levels of testosteronenone reported any side effects throughout the entire year they had been followed.

    Because clomiphene citrate isn't 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 is more effective at boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs such as clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.

    What kinds of testosterone-replacement therapy are available? *

    The earliest form is the injection, which we use because it's inexpensive and since we reliably get fantastic testosterone levels in nearly everybody. The drawback is that a man needs to come in every couple of weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and return to research.

    Topical treatments help maintain a more uniform amount of blood testosterone. The first kind of topical treatment was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area on their skin. That restricts its usage.

    The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it has a tendency to be absorbed to good degrees in about 80% to 85 percent of men, but that leaves a substantial number who don't consume enough for this to have a positive 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 make certain they are absorbing the proper amount. Our target is the mid to upper range of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within a few doses. I usually measure it after two weeks, although symptoms may not alter for a month or two.

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