Real-World trt Programs For 2012

A Harvard Specialist shares his thoughts on testosterone-replacement Treatment

It could be stated that testosterone is what makes guys, men. It gives them their characteristic deep voices, big muscles, and facial and body 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" that produces testosterone gradually becomes less effective, and testosterone levels begin to drop, by about 1 percent per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they may start to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, decreased energy, decreased muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often referred to as hypogonadism ("hypo" significance 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 only about 5% of these affected undergoing therapy.

He has developed specific experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with 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 the typical person to find a physician?

As a urologist, I tend to see men since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and any guy who complains of erectile dysfunction must possess his testosterone level checked. Men can experience different symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid out of ejaculation, and a sense of numbness in the manhood when they see or experience something which would usually be arousing.

The more of the symptoms you will find, 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're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are a number of drugs that may lessen sex drive, such as the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also reduce the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually does not go along with treatment for BPH. Erectile dysfunction does not usually go along with it , though surely if somebody has less sex drive or less interest, it's more of a challenge to get a fantastic erection.

How can you decide whether a man is a candidate for testosterone-replacement treatment?

There are just 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 methods is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with maximum testosterone have the least. But there are some guys who have reduced levels of testosterone in their blood and have no signs.

Looking purely at the biochemical numbers, The Endocrine Society* believes low testosterone for a entire testosterone level of less than 300 ng/dl, and I believe that's a sensible guide. However, no one quite agrees on a number. It's similar to diabetes, where if your fasting glucose is above 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 should you can try this out not receive testosterone treatment. For a complete copy of the instructions, log on to www.endo-society.org.

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

Well, this is 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 physicians learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the body. However, about half of the testosterone that's circulating in the blood is not readily available to the cells.

The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Almost every laboratory has a blood test to measure free testosterone. Even though it's just a small fraction of this total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with testosterone.

This professional organization urges testosterone therapy for men who have

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

Therapy is not Suggested for men who have

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

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

For years, the recommendation has been to receive a testosterone value early in the morning because levels begin to fall 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 glucose levels in men 40 and mature over the course of this day. One reported no change in typical testosterone until after 2 Between 2 and 6 p.m., it went down by 13 percent, a small amount, and probably not enough to affect identification. Most guidelines still say it's important to perform the test in the morning, but for men 40 and above, it likely does not matter much, as long as they get their blood drawn before 6 or 5 p.m.

There are a number of very interesting findings about diet. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet has not been studied thoroughly enough to make any clear recommendations.

Exogenous vs. endogenous testosterone

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

Preliminary research has shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the production of natural testosterone, also known as nitric oxide, in men. Within four to six months, each one of the men had heightened levels of testosterone; none reported any side effects during the year they were followed.

Because clomiphene citrate isn't approved by the FDA for use in men, little information exists regarding the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it's more capable of boosting testosterone compared to exogenous formulas. But unlike adrenal gland, clomiphene citrate maintains -- and potentially enriches -- sperm production. That makes drugs 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 the injection, which we use because it's cheap and since we faithfully get good testosterone levels in nearly everybody. The drawback is that a person should 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. [Watch"Exogenous vs. endogenous testosterone," above.]

Topical treatments help maintain a more uniform level of blood glucose. The first kind of topical therapy was a patch, but it has a quite large rate of skin irritation. In one study, as many as 40% of people that used the patch developed a reddish area on their skin. That limits 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. According to my experience, it has a tendency to be absorbed to great degrees in about 80% to 85% of guys, but leaves a substantial number who do not absorb sufficient for this to have a positive impact. [For details on various formulations, see table ]

Are there any drawbacks to using dyes? How long does it take for 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 are absorbing the right quantity. Our goal is 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 quickly, in just a few doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.

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