Examining No-Hassle testosterone therapy Products

A Harvard expert shares his thoughts on testosterone-replacement therapy

A meeting with Abraham Morgentaler, M.D.

It might be said that testosterone is what makes guys, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from girls. It stimulates the development of the genitals , plays a role in sperm production, fuels libido, and leads to regular erections. Additionally, it fosters the production of red blood cells, boosts mood, and assists cognition.

As time passes, the testicular"machinery" which makes testosterone slowly becomes less effective, and testosterone levels begin to drop, by about 1% per year, beginning in the 40s. As guys get in their 50s, 60s, and beyond, they might start to have symptoms and signs of low testosterone such as reduced libido and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and nausea. 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 USA. Yet it's an underdiagnosed issue, with only about 5% of those affected receiving treatment.

Studies have revealed that testosterone-replacement therapy may provide a vast range of benefits for men with hypogonadism, including enhanced 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.

Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate diseases and male sexual and reproductive difficulties. He has developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment plans he uses with his own patients, and he thinks specialists should rethink the possible connection between testosterone-replacement treatment and prostate cancer.

Symptoms and diagnosis

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

As a urologist, I have a tendency to see guys because they have sexual complaints. The primary hallmark of low testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and any guy who complains of erectile dysfunction should possess his testosterone level checked. Men can experience other symptoms, like more difficulty achieving an orgasm, less-intense orgasms, a smaller quantity of fluid from ejaculation, and a sense of numbness in the penis when they see or experience something that would usually be arousing.

The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians often dismiss those"soft symptoms" as a normal part of aging, but they're often treatable and reversible by normalizing testosterone levels.

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

Not exactly. There are quite a few drugs that may reduce libido, including the BPH medication finasteride (Proscar) and dutasteride (Avodart). Those drugs may also decrease the quantity 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 , though certainly if a person has less sex drive or less interest, it's more of a struggle to get a good erection.

How can you determine if a person is a candidate for testosterone-replacement treatment?

There are just two ways we determine whether somebody has low 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 perfect. Generally men with the lowest testosterone have the most symptoms and men with maximum testosterone possess the least. However, 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 to be a entire testosterone level of less than 300 ng/dl, and I think that is a sensible guide. However, no one really agrees on a number. It's not like diabetes, in which if your fasting glucose is above a certain level, they will say,"Okay, you've got it." With testosterone, that break point is not quite as apparent.

*Notice: The Endocrine Society publishes clinical practice guidelines with recommendations for who should and shouldn't receive testosterone treatment. See"Endocrine Society recommendations anchor summarized."

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

This is another area of confusion and great discussion, but I do not 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 overall testosterone, or all the testosterone in the human body. But about half of their testosterone that's circulating in the blood isn't available to cells. It is 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. 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 fairly good indicator of low testosterone. It's not ideal, but the correlation is greater compared to testosterone.

This professional organization recommends testosterone therapy 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 which may be felt during a DRE
  • a PSA higher than 3 ng/ml without further evaluation
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract symptoms
  • class III or IV heart failure.

Do time of day, diet, or other factors influence testosterone levels?

For many years, the recommendation has been to receive a testosterone value early in the morning because levels begin to fall after 10 or even 11 a.m.. But the data behind this 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 the day. One reported no change in typical testosterone till after 2 Between 2 and 6 p.m., it went down by 13%, a small sum, and probably not enough to affect diagnosis. Most guidelines still say it's important to do the test in the morning, but for men 40 and above, it probably doesn't matter much, provided that they obtain their blood drawn before 5 or 6 p.m.

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

Within this article, testosterone-replacement therapy refers to the treatment of hypogonadism with adrenal gland -- testosterone that's produced outside the body. Depending on the formula, therapy can cause skin irritation, breast enlargement and tenderness, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with other side effects.

Preliminary research has proven that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can foster the creation of natural testosterone, known as nitric oxide, in men. Within four to six weeks, each one of the men had heightened levels of testosteronenone reported some side effects throughout the year they were followed.

Because clomiphene citrate isn't accepted by the FDA for use in males, little information exists about the long-term ramifications of carrying it (such as the probability of developing prostate cancer) or if it is more effective at boosting testosterone compared to exogenous formulations. But unlike exogenous testosterone, clomiphene citrate maintains -- and possibly enriches -- sperm production. This makes drugs such as clomiphene citrate one of only a few options for men with low testosterone that wish to father children.

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

The earliest form is the injection, which we use because it is cheap and because we faithfully become fantastic testosterone levels in almost everybody. The drawback is that a person needs to come in every couple of weeks to get a shot. A roller-coaster effect may also occur as blood testosterone levels peak and then return to research.

Topical therapies help maintain a more uniform level of blood glucose. The first kind of topical therapy has been a patch, but it has a very large rate of skin irritation. In one study, as many as 40 percent of men who used the patch developed a reddish area on their skin. That limits its usage.

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

Are there any drawbacks to using dyes? How much time 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 make sure they're absorbing the right quantity. Our goal is that the mid to upper range of normal, which generally means around 500 to 600 ng/dl. The concentration of testosterone in the blood really goes up quite fast, in just a few doses. I normally measure it after 2 weeks, although symptoms may not alter for a month or two.

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