Sensible Advice For trt In The Uk

A Harvard expert shares his thoughts on testosterone-replacement therapy

An interview with Abraham Morgentaler, M.D.

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

As time passes, the testicular"machinery" that makes testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1 percent per year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone such as lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and nausea. 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's an underdiagnosed problem, with just about 5% of these affected receiving treatment.

Studies have revealed that testosterone-replacement therapy may provide a wide selection of advantages for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production.

He has developed specific experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he utilizes his patients, and he believes experts should reconsider the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to observe men because they have sexual complaints. The main hallmark of reduced testosterone is low sexual libido or desire, but another may be erectile dysfunction, and some other guy who complains of erectile dysfunction must possess his testosterone level checked. Men may experience other symptoms, such as more trouble achieving an orgasm, less-intense climaxes, a much lesser amount of fluid from ejaculation, and a feeling 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 probable it is that a man has low testosterone. Many physicians often discount those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by decreasing testosterone levels.

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

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

How do you determine whether or not a man is a candidate for testosterone-replacement therapy?

There are two ways we determine whether somebody has low testosterone. One is a blood test and the other is by characteristic signs and symptoms, and the correlation between those two approaches is far from ideal. Generally guys with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. However, there are some guys who have low levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone to be a entire testosterone level of less than 300 ng/dl, and I think that is a reasonable guide. But no one really agrees on a number. It is not like diabetes, in which if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

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

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

Well, this is just another area of confusion and good debate, but I don't think that it's as confusing as it appears to be from 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 blood is not available to cells. It's closely bound to a carrier molecule called 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 the cells. Even though it's only a small fraction of the total, the free testosterone level is a pretty good indicator of low testosterone. It is not ideal, but the significance is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone therapy for men who have both

Therapy is not recommended for men who have

Prostate or breast cancer
a nodule on the prostate that can be felt during a DRE
that a PSA higher than 3 ng/ml without additional evaluation
a hematocrit greater than 50 percent or thick, viscous blood
untreated obstructive sleep apnea
severe lower urinary tract infections

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

For many years, the recommendation was to receive a testosterone value early in the morning because levels start to fall after 10 or 11 a.m.. But the data behind that recommendation were attracted to 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 average testosterone until after 2 Between 2 and 6 p.m., it went down by 13%, a small amount, and probably insufficient to affect diagnosis. Most guidelines nevertheless say it is important to do the evaluation in the morning, but for men 40 and over, it probably does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

There are some rather interesting findings about dietary supplements. For instance, it appears that those who have a diet low in protein have lower testosterone levels than males who consume more protein. But diet has not been studied thoroughly enough to create any clear recommendations.

Exogenous vs. endogenous testosterone

Within this guide, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's manufactured outside the body. Based upon the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced 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, 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, each one of the men had increased levels of testosteronenone reported any side effects during the entire year they had been followed.

Since clomiphene citrate isn't accepted by the FDA for use in males, little information exists about the long-term effects of taking it (such as the probability of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few options for men with low testosterone that wish to father children.

Formulations

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

The oldest form is an injection, which we still use since it is cheap and because we reliably get fantastic testosterone levels in almost everybody. The disadvantage is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood testosterone levels peak and then return to research.

Topical treatments help maintain a more uniform level of blood glucose. The first kind of topical treatment has been a patch, but it has a quite large rate of skin irritation. In one study, as many as 40 percent of people that used the patch developed a red area in their skin. That restricts its use.

The most commonly used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. Based on my experience, it has a tendency to be consumed to great levels in about 80% to 85 percent of guys, but that leaves a significant number who do not absorb sufficient for it to have a favorable effect. [For details on various formulations, see table below.]

Are there any downsides to using gels? How much time does it require them to work?

Men who begin using the gels have to return in to have their testosterone levels measured again to be sure they're absorbing the proper amount. Our goal is that the mid to upper assortment of normal, which usually means approximately 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within a few doses. I normally measure it after 2 weeks, though symptoms may not alter for a month or two.

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