A Harvard Specialist shares his Ideas on testosterone-replacement therapy
An interview with Abraham Morgentaler, M.D.
It might be said that testosterone is what makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body hair, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. It also 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 start to drop, by about 1 percent per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed issue, with only about 5% of these affected receiving treatment.
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 may 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 sexual and reproductive difficulties. He has developed particular experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average person to find a physician?
As a urologist, I have a tendency to observe guys because they have sexual complaints. The primary 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 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 sense of numbness in the penis when they see or experience something that 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 dismiss these"soft symptoms" as a normal part of aging, however, they are often treatable and reversible by normalizing testosterone levels.
Are not those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications which may reduce libido, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. But a decrease in orgasm intensity normally doesn't go together with treatment for BPH. Erectile dysfunction does not usually go together with it either, though certainly if somebody has less sex drive or less interest, it's 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 just two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and men with maximum testosterone have the least. But there are some men who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe 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 recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. For a complete copy of the instructions, log on to www.endo-society.org. Is total testosterone the ideal point to be measuring? Or if we are measuring something else? This is another area of confusion and good discussion, but I don't think that it's as confusing as it appears to be from the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all the testosterone in the human body. But about half of their testosterone that's circulating in the blood is not available to cells. The biologically available portion of total testosterone is known as free testosterone, and it's readily available to cells. Nearly every lab has a blood test to measure free testosterone. Though it's only a little fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not ideal, but the correlation is greater than with testosterone.
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