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A meeting with Abraham Morgentaler, M.D.

It could be stated that testosterone is what makes guys, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. It also boosts the production 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 fall, by approximately 1% per year, beginning in the 40s. As men get in their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone such as lower libido and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" significance low functioning and"gonadism" referring 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% of those affected undergoing therapy.

But little consensus exists on 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's developed specific expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his patients, and why he thinks specialists should rethink the potential link between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to observe men because they have sexual complaints. The primary hallmark of low testosterone is reduced 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 climaxes, a much lesser 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 often discount those"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.

Aren't those the same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?

Not precisely. There are a number of drugs that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs may 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 ordinarily go together with it , though certainly if somebody has less sex drive or less interest, it's more of a struggle to have a fantastic erection.

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

There are two ways that we determine whether somebody has low testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two approaches is far from ideal. Normally guys with the lowest testosterone have the most symptoms and men with highest testosterone have the least. But there are a number of guys who have reduced levels of testosterone in their blood and have no signs.

Looking at the biochemical amounts, The Endocrine Society* believes low testosterone for a total 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's not like diabetes, in which if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as clear.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and shouldn't receive testosterone therapy.

Is total testosterone the ideal thing to be measuring? Or should we be measuring something different?

This is another area of confusion and good debate, but I don't think that it's as confusing as it appears to be in the literature. When most physicians learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. But about half of their testosterone that's circulating in the bloodstream isn't available to cells. It's closely bound to a carrier molecule called 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 the cells. Even 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 compared to total testosterone.

Endocrine Society recommendations summarized This professional organization urges testosterone therapy for men who have Therapy Isn't recommended for men who've Prostate or breast cancer a nodule on the prostate which can be felt during a DRE that a PSA greater than 3 ng/ml without further analysis a hematocrit greater than 50 percent or thick, viscous blood untreated obstructive sleep apnea severe lower urinary tract symptoms class III or their website IV heart failure. Do time daily, diet, or other elements affect testosterone levels? For years, the recommendation was to get a testosterone value early in the morning because levels begin to drop after 10 or 11 a.m.. However, the data behind that recommendation were attracted to healthy young men. Two recent studies showed little change in blood testosterone levels in men 40 and mature over the course of the day. One reported no change in typical testosterone till after 2 Between 6 and 2 p.m., it went down by 13%, a modest amount, and probably insufficient to influence identification. Most guidelines nevertheless say it is important to do the test in the morning, however for men 40 and over, it probably doesn't matter much, as long as they obtain their blood drawn before 6 or 5 p.m. There are some very interesting findings about diet. For instance, it seems that those who 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 create any clear recommendations. Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based upon the formula, therapy can lead to skin irritation, breast enlargement and tenderness, sleep apnea, acne, reduced sperm count, increased red blood cell count, and other side effects. Within four to six months, all the guys had increased levels of testosteronenone 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 regarding the long-term ramifications of carrying it (such as the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and potentially enriches -- sperm production. That makes drugs like clomiphene citrate one of just a few options for men with low testosterone who want to father children.

Formulations

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

The earliest form is the injection, which we still use because it's cheap and since we reliably get good testosterone levels in almost everybody. The drawback is that a man needs to come in every few weeks to find a shot. A roller-coaster effect may also occur as blood testosterone levels peak and return to baseline.

Topical therapies help preserve a more uniform amount 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 use.

The most commonly used testosterone preparation from the United States -- and also the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. Based on my experience, it has a tendency to be consumed to good degrees in about 80% to 85 percent of men, but leaves a substantial number who do not consume enough for this to have a favorable effect. [For specifics on several different formulations, see table below.]

Are there any drawbacks to using dyes? How much time does it take for them to get the job done?

Men who begin using the gels have to return in to have their testosterone levels measured again to make certain 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 the blood really goes up quite fast, within several doses. I usually measure it after 2 weeks, although symptoms may not alter for a month or two.