Programs In trt - An Analysis

A Harvard Specialist shares his thoughts on testosterone-replacement Treatment

It could be stated that testosterone is the thing that makes guys, guys. It gives them their characteristic deep voices, large muscles, and facial and body hair, differentiating them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it boosts the production of red blood cells, boosts mood, and aids cognition.

Over time, the testicular"machinery" that makes testosterone slowly becomes less powerful, and testosterone levels begin to fall, by about 1% a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they might begin to have symptoms and signs of low testosterone like reduced libido and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism ("hypo" meaning low functioning and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it's an underdiagnosed issue, 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.

He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he uses with his patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to observe men because they have sexual complaints. The main hallmark of low testosterone is low sexual desire or libido, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more trouble achieving an orgasm, less-intense orgasms, a much lesser amount of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would normally be arousing.

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

Are not those the same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of medications that may reduce libido, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity of the ejaculatory fluid, no question. However a reduction in orgasm intensity normally does not go together with treatment for BPH. Erectile dysfunction does not ordinarily go along with it , though surely if somebody has less sex drive or less interest, it's more of a struggle to get a fantastic erection.

How do you determine if a person is a candidate for testosterone-replacement therapy?

There are just two ways that we determine whether someone has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two approaches is far from perfect. Generally guys with the lowest testosterone have the most symptoms and men with maximum 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 purely 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 reasonable guide. However, no one quite agrees on a number. It is not like diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations link for who should and shouldn't receive testosterone treatment. For this contact form a complete great site copy of these instructions, log on to www.endo-society.org.

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

Well, this is another area of confusion and good discussion, but I don't think that 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 the testosterone in the body. But about half of their testosterone that is 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 biologically available part of total testosterone is known as free testosterone, and it is readily available to cells. Almost every lab has a blood test to measure free testosterone. Though it's just a little fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with total testosterone.

This professional organization urges testosterone therapy for men who have both

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

Therapy is not recommended for men who've

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

Do time of day, diet, or other factors affect testosterone levels?

For years, the recommendation has been to get a testosterone value early in the morning because levels start to drop after 10 or even 11 a.m.. But the data behind that recommendation were drawn from healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and older over the course of the day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a small sum, and probably insufficient to influence diagnosis. Most guidelines still say it's important to do the evaluation in the morning, however 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 rather interesting findings about dietary supplements. For example, it appears that those 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 create any recommendations that are clear.

In this article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending on the formula, treatment can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

Preliminary studies have proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, termed nitric oxide, in men. At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six months, all of the guys had heightened levels of testosteronenone reported some side effects throughout the year they had been followed.

Because clomiphene citrate is not accepted by the FDA for use in men, little information exists regarding the long-term ramifications of taking it (such as the risk of developing prostate cancer) or if it is more capable of boosting testosterone compared to exogenous formulations. But unlike adrenal gland, clomiphene citrate preserves -- and potentially enhances -- sperm production. This makes medication like clomiphene citrate one of just a few choices for men with low testosterone that want to father children.

What kinds of testosterone-replacement therapy can be found? *

The oldest form is the injection, which we still use since it's cheap and because we faithfully get fantastic testosterone levels in nearly everybody. The drawback is that a man should come in every few weeks to find a shot. A roller-coaster effect can also occur as blood glucose levels peak and then return to research.

Topical treatments help maintain a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a quite high rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a reddish area on their skin. That limits its use.

The most widely used testosterone preparation in the United States -- and the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it tends to be consumed to good levels in about 80% to 85 percent of men, but leaves a substantial number who do not absorb sufficient for this to have a positive effect. [For details on several different formulations, see table below.]

Are there any downsides to using dyes? How long does it take for them to get the job done?

Men who begin using the gels have to come back in to have their own testosterone levels measured again to be sure they're absorbing the proper quantity. Our target is the mid to upper range of normal, which generally means approximately 500 to 600 ng/dl. The concentration of testosterone in the blood actually goes up quite quickly, in just several doses. I usually measure it after two weeks, though symptoms may not change for a month or two.

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