Examining No-Hassle hrt Products

A meeting with Abraham Morgentaler, M.D.

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, differentiating them from women. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and leads to normal erections. Additionally, it boosts the production of red blood cells, boosts mood, and assists cognition.

Over time, the testicular"machinery" which makes testosterone slowly 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 symptoms and signs of low testosterone like reduced sex drive 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 problem, with only about 5% of these affected undergoing therapy.

Studies have shown that testosterone-replacement therapy can provide a wide range of benefits for men with hypogonadism, such as improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists about 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 experience in treating lower testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and why he believes specialists should rethink the potential connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I tend to see 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 must possess his testosterone level checked. Men can experience different symptoms, like more trouble achieving an orgasm, less-intense climaxes, a much lesser quantity 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 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 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 usually go along with it either, though surely if a person has less sex drive or less attention, it's more of a challenge to get a good erection.

How can you decide if a man is a candidate for testosterone-replacement therapy?

There are just two ways 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 approaches is far from ideal. Normally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, there are some men who have reduced levels of testosterone in their blood and have no symptoms.

Looking purely at the biochemical amounts, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a sensible guide. However, no one quite agrees on a few. It is similar to diabetes, where if your fasting glucose is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.

*Note: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. Is complete testosterone the right thing to be measuring? Or if we are measuring something else? This is just another area of confusion and great discussion, but I don't think that it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they heard about total testosterone, or all of the testosterone in the body. However, about half of their testosterone that's circulating in the blood is not available to cells. The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Even though it's just a small portion of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater than with total testosterone. This professional organization recommends testosterone treatment for men who have both Low levels of testosterone in the blood (less than 300 ng/dl) symptoms of low testosterone. Therapy Isn't recommended for men who've 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 analysis that a hematocrit greater than 50% or thick, viscous blood untreated obstructive sleep apnea severe lower urinary tract infections class III or this page IV heart failure. Do time daily, diet, or other elements influence testosterone levels? For many years, the recommendation was to receive a testosterone value early in the morning since levels begin to drop after 10 or even 11 a.m.. But 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 within 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 percent, a small sum, and probably insufficient to influence 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, provided that they obtain their blood drawn before 5 or 6 p.m. There are a number of very interesting findings about dietary supplements. By way of instance, it seems that those who have a diet low in protein have lower testosterone levels than males who eat more protein. But diet hasn't been researched thoroughly enough to make any recommendations that are clear. Within the following article, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that's produced outside the body. Based upon the formulation, therapy can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects. Within four to six weeks, each one the guys had heightened levels of testosterone; none reported any side effects throughout the entire year they had been followed. Because clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of carrying it (such as the risk of developing prostate cancer) or whether it's more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. This makes medication such as clomiphene citrate one of only a few options for men with low testosterone who wish to father children.

Formulations

What kinds of testosterone-replacement therapy are available? *

The oldest form is an injection, which we use because it is inexpensive and since we reliably get good testosterone levels in nearly everybody. The disadvantage is that a person needs to come in every few weeks to get a shot. A roller-coaster effect may also occur as blood testosterone levels peak and then return to research. [See"Exogenous vs. endogenous testosterone," above.]

Topical therapies help preserve a more uniform level of blood glucose. The first form of topical treatment was a patch, but it has a quite high rate of skin irritation. In 1 study, as many as 40% of men who used the patch developed a red area on their skin. That restricts its use.

The most commonly used testosterone preparation in the United States -- and also the one I start almost everyone off -- is a topical gel. There are two brands: AndroGel and Testim. The gel comes from miniature tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. According to my experience, it has a tendency to be consumed to great degrees in about 80% to 85% of guys, but leaves a substantial number who don't consume enough for it to have a favorable impact. [For details on several different formulations, see table ]

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

Men who start using the gels have to come back in to have their own testosterone levels measured again to be certain they're absorbing the proper 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 two weeks, though symptoms may not change for a month or two.