Sensible Advice For trt In The Uk

A Harvard Specialist shares his thoughts 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 body and facial hair, distinguishing them from girls. It stimulates the development of the genitals at puberty, plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it fosters the production 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% per year, beginning in the 40s. As guys get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like lower libido and sense of energy, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often called hypogonadism ("hypo" significance low functioning and"gonadism" speaking to the testicles). Yet it is an underdiagnosed issue, with only about 5 percent of these affected receiving treatment.

Various studies have shown that testosterone-replacement therapy can offer a wide selection of benefits for men with hypogonadism, including enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production.

He has developed specific expertise in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his own patients, and why he believes specialists should rethink the possible link between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to observe guys since they have sexual complaints. The primary hallmark of low testosterone is low sexual libido or desire, but another may be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men can experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a smaller quantity of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something which 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 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're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also decrease the amount of the ejaculatory fluid, no question. But a reduction in orgasm intensity usually does not go along with treatment for BPH. Erectile dysfunction does not usually go along with it either, though certainly if somebody has less sex drive or less interest, it is more of a challenge to get a fantastic erection.

How can you decide if or not a person is a candidate for testosterone-replacement treatment?

There are just two ways that we determine whether someone has reduced testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Normally guys with the lowest testosterone have the most symptoms and guys 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 numbers, The Endocrine Society* considers low testosterone for a entire testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. However, no one really agrees on a few. It is not like diabetes, where if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as clear.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. Watch"Endocrine Society recommendations site link summarized."

Is total testosterone the ideal point to be measuring? Or should we be measuring something else?

This is just another area of confusion and great debate, but I do not 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 total testosterone, or all the testosterone in the body. However, about half of their testosterone that's circulating in the bloodstream isn't readily available to the cells. It's closely bound to a carrier molecule known as sex hormone--binding globulin, which we abbreviate as SHBG.

The biologically available part of overall testosterone is called free testosterone, and it's readily available to cells. Almost every laboratory has a blood test to measure free testosterone. Though it's just a small fraction of this overall, the free testosterone level is a pretty good indicator of low testosterone. It is not perfect, but the significance is greater compared to total testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have both

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

Therapy Isn't recommended for men who've

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 symptoms

class III visit or IV heart failure.

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

For years, the recommendation has been to receive a testosterone value early in the morning because levels begin to drop after 10 or 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of this day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a modest sum, and probably not enough to influence identification. Most guidelines still say it's important to perform the test in the morning, but for men 40 and over, it likely doesn't matter much, as long as they obtain their blood drawn before 6 or 5 p.m.

There are some rather interesting findings about dietary supplements. For example, it seems that those that have a diet low in protein have lower testosterone levels than men who consume more protein. But diet has not been researched thoroughly enough to make any recommendations that are clear.

Exogenous vs. endogenous testosterone

In the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based on the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, and other side effects.

Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, may boost the creation of natural testosterone, also termed endogenous testosterone, in men. Within four to six months, each one the men had heightened levels of testosterone; none reported any side effects during the year they were followed.

Because clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term effects of taking it (including the risk 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. This makes medication such as clomiphene citrate one of just a few options for men with low testosterone that wish to father children.

What forms of testosterone-replacement therapy are available? *

The oldest form is an injection, which we use because it's inexpensive and because we faithfully become fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to get a shot. A roller-coaster effect may also happen as blood glucose levels peak and return to baseline.

Topical treatments help preserve a more uniform level of blood testosterone. The first form of topical treatment has been a patch, but it has a very high rate of skin irritation. In 1 study, as many as 40 percent of men who used the patch developed a red area in their skin. That restricts its usage.

The most commonly used testosterone preparation in the United States -- and also the one I begin almost everyone off with -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it has a tendency to be consumed to good levels in about 80% to 85 percent of men, but that leaves a significant number who do not absorb enough 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 require them to get the job done?

Men who start using the implants need to return in to have their testosterone levels measured again to be sure they're absorbing the proper amount. Our goal is the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite fast, within several doses. I usually measure it after two weeks, even though symptoms may not alter for a month or two.

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