A Harvard Specialist shares his thoughts on testosterone-replacement therapy
A meeting with Abraham Morgentaler, M.D.
It could be stated that testosterone is the thing that makes men, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the creation of red blood cells, boosts mood, and assists cognition.
As time passes, the "machinery" that produces testosterone gradually becomes less effective, and testosterone levels start to fall, by approximately 1% per year, starting in the 40s. As guys get in their 50s, 60s, and beyond, they might begin to have signs and symptoms of low testosterone like reduced sex drive and sense of energy, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs 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 USA. Yet it is an underdiagnosed problem, with only about 5% of those affected receiving treatment.
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 particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and he believes experts should reconsider the possible connection between testosterone-replacement treatment and prostate cancer.
Symptoms and diagnosisWhat symptoms and signs of low testosterone prompt the typical person to find a physician?
As a urologist, I have a tendency to see men because they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction should 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 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 tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by normalizing testosterone levels.
Are not 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 that may lessen sex drive, such as the BPH medication 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 therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if a person has less sex drive or less attention, it is more of a struggle to have a good erection.
How do you determine if or not a person is a candidate for testosterone-replacement treatment?
There are two ways that 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. Generally men with the lowest testosterone have the most symptoms and men with highest testosterone possess the least. But 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 for a total testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. But no one quite agrees on a number. It's similar to diabetes, in which 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 treatment. See"Endocrine Society recommendations summarized." For a complete copy of the guidelines, log on to www.endo-society.org. Is complete 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 do not think that it's as confusing as it is apparently from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the body. But about half of the testosterone that is circulating in the blood isn't available to the cells. It is closely 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 cells. Nearly every lab has a blood test to measure free testosterone. Even though it's only a little portion of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the correlation is greater compared to total testosterone.
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