Testosterone for Life by Abraham Morgentaler
Testosterone for Life by Abraham Morgentaler | 1.27 MB
216 Pages
Title: Testosterone for Life: Recharge Your Vitality, Sex Drive, Muscle Mass, and Overall Health
Author: Abraham Morgentaler
Description:
"Dr. Morgentaler, an internationally recognized expert in sexual medicine and male hormones, shares his secrets for a healthy life."
--Irwin Goldstein, M.D. , Director of Sexual Medicine, Alvarado Hospital, San Diego, and Editor-in-Chief, Journal of Sexual Medicine
"A highly valuable resource. Finally debunks many of the myths about testosterone's safety, which has been an impediment to its appropriate usage for far too long."
--David E. Greenberg, M.D. , President, Canadian Society for the Study of the Aging Male
From a Harvard doctor and a leading expert on testosterone--the groundbreaking book that shows you how to raise your testosterone levels--and live your life to the fullest
Better sex. Increased vitality. More muscle. Improved health. Greater mental agility. These are just a few of the life-enhancing benefits that men with low levels of testosterone can experience when they increase their testosterone level. If you've noticed a decrease in your sex drive; experienced erectile dysfunction; or felt tired, depressed, and unmotivated, this authoritative, up-to-date guide from an expert at Harvard Medical School will help you determine if you have low testosterone--a surprisingly common but frequently undiagnosed condition among middle-aged men. Learn how to:
From the Publisher
Abraham Morgentaler, M.D. , is an Associate Clinical Professor of Urology at Harvard Medical School, and is the founder of Men's Health Boston, a center focusing on sexual and reproductive health for men. He is the author of a number of popular books including The Male Body and The Viagra Myth.
About the Author
Abraham Morgentaler, M.D. , is an Associate Clinical Professor of Urology at Harvard MedicalSchool, and is the founder of Men's Health Boston, a center focusing on sexual and reproductivehealth for men. He is the author of a number of popular books including The Male Body and The Viagra Myth.
Excerpt. © Reprinted by permission. All rights reserved.
Testosterone for Life
Recharge Your Vitality, Sex Drive, Muscle Mass & Overall Health! By ABRAHAM MORGENTALER
The McGraw-Hill Companies, Inc.
Copyright © 2009 President and Fellows of Harvard University
All right reserved.
ISBN: 978-0-07-149480-9
Contents
Chapter One
Recognizing the Symptoms
This book is written to help men determine whether they have low testosterone and, if so, how best to obtain treatment. The first step, then, is to recognize the symptoms of low testosterone, or low T.
As many as 20 percent of men over fifty years of age may have low levels of testosterone in their bloodstream, but only a fraction of this number have symptoms. As more research is done and low T is better understood, it is possible, perhaps even likely, that we will come to treat asymptomatic men as well. There is growing evidence, for example, that low T is associated with an increased risk of diabetes, atherosclerosis (hardening of the arteries, which can lead to heart attacks or strokes), and weak bones, but as yet these observations are not reason enough to begin testosterone treatment. At this time, the primary reason to treat men with low T is to alleviate symptoms.
Testosterone has a wide variety of actions throughout the body, so it should be no surprise that there are multiple symptoms of low T. Some men may have just one symptom, while others may have a whole list of symptoms, all of which may be addressed by testosterone treatment.
As you read these stories, see if you recognize yourself in any of them. Remember that everyone is different and that the symptoms of low T can be different from one individual to another. If you have one or more of the symptoms described by men in these stories, then it may be worthwhile for you to have a blood test to determine whether you have low T.
Low Sex Drive
The hallmark symptom of low T is low libido, or low sex drive. The relationship between testosterone and sex drive has been known for a long time, so that even when people have no medical background at all, if someone says he has no interest in sex, his friends may joke that he has "low testosterone."
Jerry was a fifty-four-year-old patient with a remarkable story. His first wife had passed away ten years earlier from cancer, and he had raised his two children into adulthood on his own. While he was working and taking care of his children, he felt he didn't have time for a relationship. Now that his kids were on their own, he met and married a woman twelve years younger. "Clarice is great, and I'm very lucky to have such an attractive wife," he said. "But even though I know she's attractive, I just don't have the urge to do anything sexual with her." He paused for a moment. "Or with anyone, for that matter," he added.
Jerry described his situation further. "It's like a part of me is switched off. Once in a great while we have sex, maybe once every month or two. I can get hard, but I have to really concentrate to stay hard, and it's a struggle. My other doctor gave me some of those erection pills—they did help me stay hard but didn't change my interest."
"How long has it been since you had a strong interest in sex?" I asked.
"I couldn't really tell you, Doctor. My first wife and I had an active sex life until we had kids, and then it changed a bit, like it probably does for everyone. But then she got sick, and I never really paid too much attention to sex until I met Clarice years later."
I asked Jerry what he hoped to achieve by his consultation with me, and he responded, "I actually don't want anything for myself. But Clarice deserves more from me. She's a younger woman, she took a chance on a guy like me with two kids already, and she deserves to have sex on a regular basis. She likes it, and she tells me she feels closer to me after it happens." Jerry shifted in his chair. "I'll tell you a story. Last Valentine's Day we went with three other couples up to this nice inn in Vermont for the night. We all had a great dinner, and then everyone joked about heading up to their rooms to have sex. When we got up to the room, I climbed into bed, turned off the light, and went to sleep. It was embarrassing."
Jerry's past medical history gave no clues as to what may have been causing his difficulties. Some medicines can cause sexual problems, but the only prescription medicine he took was for high cholesterol—a medicine that doesn't usually cause sexual problems. Depression can cause lack of sexual desire or performance, but Jerry had no history of depression. When his blood tests came back, however, it showed that his testosterone levels were low.
I started Jerry on testosterone treatment with gel. At first, he noted no changes in his sexual desire, and blood tests showed that his T levels had increased only into the lower range of normal. I then increased the dose of gel, and his blood tests showed excellent levels of testosterone, in the midrange of normal. Jerry reported that he started waking up with erections in the morning. "It's like seeing an old friend again," he said with some pleasure. This was a positive sign.
"Give it a couple of months now," I advised.
Two months later, Jerry returned with Clarice by his side. They made an interesting couple, Jerry his usual disheveled self and Clarice a petite, pretty woman who was well put-together.
"How are things going?" I asked, after Clarice and I had introduced ourselves.
They both smiled. "Great!" Jerry exclaimed. "Clarice says I'm like a teenager the way I'm after her all the time." Jerry looked over at Clarice and they seemed to share a momentary private joke. "I don't think it's that extreme," he said, "but we're having sex on a regular basis now, at least once or twice a week. And I think about sex again, even when we're not doing anything. I'd forgotten what that was like, but I remember that I used to do that all the time, before my first wife got sick."
"Have you noticed any other changes in Jerry since he started treatment?" I asked Clarice.
"Definitely," she replied. "It's hard to know whether it's the testosterone itself, or just one good thing leading to another, but Jerry seems happier. He jokes around with me in ways he only rarely did before. He makes decisions more quickly. For example, when I used to ask him what movie he wanted to see, he would usually just turn it around and ask me what I wanted to see. But now he'll tell me what he's interested in. It's like Jerry has emerged from his shell."
Clarice's description of the changes in Jerry was typical of what I hear from the partners of men treated with testosterone. Many times, men come in for a specific symptom, such as low libido or erectile dysfunction, and they evaluate the response to treatment by focusing only on those original symptoms. But subtle changes in how a man acts or the energy he gives off in day-to-day interactions may be less visible to the person himself, but obvious to the people around him. Often, the man will deny noticing any other changes with treatment, while his partner will turn to me and say with conviction, "Oh yeah, he's different."
One other point to make about Jerry's case. Although there can be a number of reasons why T levels can be low in men, the most common by far is the gradual decline in testosterone that accompanies aging. This doesn't mean that Jerry was old—some men will have normal T levels into their eighties. But it is often difficult to pinpoint the moment when libido changes or disappears. Slow changes can be difficult to notice, especially when they happen over many years and when there are major stresses going on in life. In Jerry's case, there was a period of many years when he was coping with the grief of his first wife's death and the challenges of raising his children alone. At some point during that stressful period, Jerry's testosterone levels likely dropped into the low range, but he didn't notice it because of everything else going on in his life. This is true for many men.
Low Energy, or "The Couch Speaks to Me"
I still laugh when I think of Richard's story. Like most physicians, I have my patients fill out a form before I see them on which they list their medical information, such as current medications, allergies, and prior operations. Near the top of the form is a line that asks, "What is your reason for seeing the doctor?"
In response to this question, Richard had written: "The couch speaks to me." I wasn't sure what this meant. When I entered the exam room, there was Richard, a tall, lanky guy, forty-six years old, who greeted me with a big smile and a shock of red hair hanging over his forehead, which he swept away with a big, calloused hand.
"So," I asked, curious, "what do you mean, 'The couch speaks to me'?"
"Doctor," Richard began, "I've always been a busy guy. I hold two jobs, not because I need the money, but because I like being busy. And on nights and weekends, I'm always in my shop in the basement, working on projects. Ever since I was a kid, I've been 'Go, go, go.' But over the last couple of years, every time I walk across my living room, I hear the couch call out to me, saying," and here Richard cupped his hands to his mouth, as if calling someone far away, "'Come! Lie down! Take a nap!' "
Richard grinned at me, pleased with his performance, and I couldn't help but laugh out loud. He went on, "Doc, taking naps in the middle of the day just isn't me. I'm not depressed, my life is great otherwise, I don't have any major stresses in my life. I just feel like there is something different about my body and my brain, and I'm wondering if it's low testosterone."
Richard denied having any other symptoms of low T. His erections were fine, his libido was strong, his mood was good and upbeat. The only thing he complained about was that he just didn't have the same energy level and drive to be busy that had defined him his whole life.
Sure enough, Richard's T levels came back low. I started him on testosterone therapy and saw him back in follow-up a couple of months later.
"How are you?" I asked.
"Doc," he replied, "the couch doesn't speak to me anymore. I'm cured."
Richard's story highlights the impact of low T on what we call energy or motivation or fatigue. Energy may sound like the opposite of fatigue, and motivation can be synonymous for energy in some circumstances, but many men make distinctions between these words in using them to describe how they feel. Another overlapping word and feeling is having a sense of vitality, a feeling of being alive. The loss of these can be due to low T, and all may resolve with treatment.
The subtlety of these feelings makes them hard to study. And sometimes the response to treatment may be more obvious to those around him than to the man himself. Many times I've heard the man's partner tell me, "There's something different about him. He just seems so much more ... alive."
Erectile Dysfunction
Samuel was a seventy-two-year-old, wiry man who saw me for erectile dysfunction. "I've been married for forty-four years to the same wonderful woman. Doc, she's as beautiful today as the day she became my bride. But for the last two years, I just can't get an erection that's firm enough to have sex anymore. My regular doctor gave me a prescription for all three of the erection pills out there, Cialis, Viagra, Levitra, you name it, and they all help a little bit, but not enough to make a difference."
I asked about his libido. "Oh, the desire is there, all right." He gave me a wink. "No problem in that department. And we've figured out other ways to stay physical, if you get my meaning, and I can still come. But I'm just never hard anymore. Used to be that I would wake up with a good erection from time to time or masturbate and get hard, but not anymore."
Samuel's normal sexual desire suggested that maybe low T was not the source of his erection difficulties, which we often call ED, for the technical term erectile dysfunction. Samuel had other reasons to have ED—hypertension and high cholesterol can both contribute to vascular disease, which in turn can cause ED. Samuel also took a number of prescription medications for those problems, which can sometimes contribute to ED. Given his age and medical conditions, it would have been reasonable to assume that Samuel's erection problem was due to blood vessel problems, specifically atherosclerosis. Tests performed in my office did indeed show some compromise of Samuel's blood vessels to the penis. In addition, blood tests showed low levels of testosterone.
When Samuel returned to discuss his test results, I explained to him that he had at least two possible reasons for his ED, one being poor blood vessels and the other being low T. Although normalizing Samuel's testosterone would be highly unlikely to improve his blocked arteries, it might still help his erections.
Samuel agreed and returned three months after beginning therapy. "Good job, Doc," he said when I entered the room. "The testosterone isn't a home run, but at least I get on base now," he joked. "What I've noticed since starting the testosterone is that I get aroused more quickly, and my penis gets harder than before. It's still not hard enough for me to have sex without any help. But the important thing is that the pills work now—just about every time. I can have sex again as long as I remember to take a pill."
As I mentioned at the beginning of the chapter, men may have one symptom of low T without having any of the others. This was true for Samuel. His libido, the hallmark symptom of low T, was unaffected by his low T levels, and he did not notice any change when his T levels were increased. Samuel's ED, though, had a component that was due to the low T. Men seem to have individual "thermostats" or thresholds, for each of the various symptoms of low T.
Recent studies in humans and animals show that there are receptors for testosterone in the corpora cavernosa of the penis, the chambers where erection takes place. These receptors send out chemical signals that are involved in the erection process. No wonder, then, that testosterone treatment has been shown to "rescue" erections in men with ED who have already had treatment with the erection-enhancing pills.
In one study of men who had failed full-dose treatment with sildenafil (Viagra), treatment of low T resulted in one-third of the men being able to have sex without any other medications at all, another third being able to have sex with testosterone therapy and the erection pills combined, and the last third were still unable to have sex. Testosterone can be an effective treatment for many men with erectile dysfunction.
Decreased Muscle Mass
Jack came to see me for a different reason. Now fifty-eight years old, he'd been an athlete his whole life, making it as a professional football player briefly in his twenties, then slimming down as a "fitness freak," in his words, for the rest of his life. He participated in marathons, cycling events, and whatever else he could find to test his body.
"I know what my body is capable of and how it responds to exercise," Jack told me. "For the last year or two, when I go to the gym after being away from it for a few months, I just can't build up the way I used to. Over the last eight weeks, I've been stuck with the same weight when I bench-press and can't move up. In the past, I would have been adding more weight every week or two."
"How would you like me to help you?" I asked.
"I'm not looking for miracles," Jack said, "and I'm not interested in being Superman. Or Schwarzenegger," he smiled wryly. "But it's important to me to be fit, stay fit. Right now, I'm feeling old, and I never felt that way before. If you can help me feel the way I think I should, that would be great. My primary care doctor tested my blood and told me my testosterone was in the low-normal range, but he wasn't sure what to do about it or whether it was causing my symptoms because I don't have any sexual problems at all. So he suggested I talk to you about it."
I ran through the various symptoms of low T, and indeed, Jack had none of them other than the feeling that he wasn't as vigorous as he once was and that his muscular response to exercise wasn't as good as it had been in the past. One other symptom he noted was that it took longer for his body to recharge after a heavy workout. When I looked at Jack's previous lab results, his total testosterone, the test used by most physicians, was just within the normal range suggested by the laboratory, but it was actually indicative of low T.
Jack started treatment with testosterone. He didn't like the gels, because he worked out so frequently that he was afraid he would sweat it off, so he underwent injections in my office every two weeks. Later he learned how to give himself injections in the thigh. I monitored his levels closely because the goal was to get him back into the normal range for men, not to get his levels up into the stratosphere, like bodybuilders and athletes using steroids for performance enhancement.
Jack was gratified with the results. "I'm OK again," he volunteered. "I can't do what I did when I was twenty-five years old, but then, I'm not twenty-five anymore. I've been moving up on my weights in the gym, and my muscles recover more quickly from the big workouts. The big thing is, I don't feel like an old man anymore."
When It's Not Low Testosterone
As can be seen from the stories of these men, testosterone treatment in men with low T can produce a fairly wide number of beneficial results. Let's be clear, though, that testosterone is not the solution to every symptom, nor does it work in everyone. After all, even men with completely normal levels of testosterone can have ED, low sex drive, or poor energy. Sometimes the cause of a man's symptoms is just life—stress, medical conditions, relationship issues, trouble at work.
Two of the common factors that may cause symptoms suggestive of low T are depression and medications. Alphonse's story underscores this nicely. Alphonse was a forty-four-year-old construction worker who came in with his wife, Sherry. When I asked Alphonse how I could help him, he turned to Sherry. "Why don't you tell him?" he suggested.
"Al was diagnosed with diabetes three years ago, and then he became depressed. He's better now, but we have two problems. One is that he has almost no interest in sex. We have sex every three months or so. The other is that we'd like to have a baby. I've been off the pill for four years, and we don't use anything else for birth control. But if we don't have sex, it's obviously hard for me to get pregnant."
Sherry continued, "We've been through a lot together. When we first started talking about having a child together ..." She paused and corrected herself. "When I first started talking about having a baby, Al didn't say no, but he didn't say yes. He seemed to be struggling with the idea, and I think part of what happened is that he didn't want to have sex with me because he wasn't ready to be a father. We've talked about it more over the last year or two, and now I think we're both ready. At least, Al seems ready. But we still almost never have sex."
(Continues...)
Excerpted from Testosterone for Lifeby ABRAHAM MORGENTALER Copyright © 2009 by President and Fellows of Harvard University. Excerpted by permission of The McGraw-Hill Companies, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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"Dr. Morgentaler, an internationally recognized expert in sexual medicine and male hormones, shares his secrets for a healthy life."
--Irwin Goldstein, M.D. , Director of Sexual Medicine, Alvarado Hospital, San Diego, and Editor-in-Chief, Journal of Sexual Medicine
"A highly valuable resource. Finally debunks many of the myths about testosterone's safety, which has been an impediment to its appropriate usage for far too long."
--David E. Greenberg, M.D. , President, Canadian Society for the Study of the Aging Male
From a Harvard doctor and a leading expert on testosterone--the groundbreaking book that shows you how to raise your testosterone levels--and live your life to the fullest
Better sex. Increased vitality. More muscle. Improved health. Greater mental agility. These are just a few of the life-enhancing benefits that men with low levels of testosterone can experience when they increase their testosterone level. If you've noticed a decrease in your sex drive; experienced erectile dysfunction; or felt tired, depressed, and unmotivated, this authoritative, up-to-date guide from an expert at Harvard Medical School will help you determine if you have low testosterone--a surprisingly common but frequently undiagnosed condition among middle-aged men. Learn how to:
- Recognize the symptoms of low testosterone
- Diagnose the problem with simple tests
- Find the treatment that's right for you
- Explore options your doctor might not know about
- Reduce your risk of cardiovascular disease and obesity
From the Publisher
Abraham Morgentaler, M.D. , is an Associate Clinical Professor of Urology at Harvard Medical School, and is the founder of Men's Health Boston, a center focusing on sexual and reproductive health for men. He is the author of a number of popular books including The Male Body and The Viagra Myth.
About the Author
Abraham Morgentaler, M.D. , is an Associate Clinical Professor of Urology at Harvard MedicalSchool, and is the founder of Men's Health Boston, a center focusing on sexual and reproductivehealth for men. He is the author of a number of popular books including The Male Body and The Viagra Myth.
Excerpt. © Reprinted by permission. All rights reserved.
Testosterone for Life
Recharge Your Vitality, Sex Drive, Muscle Mass & Overall Health! By ABRAHAM MORGENTALER
The McGraw-Hill Companies, Inc.
Copyright © 2009 President and Fellows of Harvard University
All right reserved.
ISBN: 978-0-07-149480-9
Contents
Chapter One
Recognizing the Symptoms
This book is written to help men determine whether they have low testosterone and, if so, how best to obtain treatment. The first step, then, is to recognize the symptoms of low testosterone, or low T.
As many as 20 percent of men over fifty years of age may have low levels of testosterone in their bloodstream, but only a fraction of this number have symptoms. As more research is done and low T is better understood, it is possible, perhaps even likely, that we will come to treat asymptomatic men as well. There is growing evidence, for example, that low T is associated with an increased risk of diabetes, atherosclerosis (hardening of the arteries, which can lead to heart attacks or strokes), and weak bones, but as yet these observations are not reason enough to begin testosterone treatment. At this time, the primary reason to treat men with low T is to alleviate symptoms.
Testosterone has a wide variety of actions throughout the body, so it should be no surprise that there are multiple symptoms of low T. Some men may have just one symptom, while others may have a whole list of symptoms, all of which may be addressed by testosterone treatment.
As you read these stories, see if you recognize yourself in any of them. Remember that everyone is different and that the symptoms of low T can be different from one individual to another. If you have one or more of the symptoms described by men in these stories, then it may be worthwhile for you to have a blood test to determine whether you have low T.
Low Sex Drive
The hallmark symptom of low T is low libido, or low sex drive. The relationship between testosterone and sex drive has been known for a long time, so that even when people have no medical background at all, if someone says he has no interest in sex, his friends may joke that he has "low testosterone."
Jerry was a fifty-four-year-old patient with a remarkable story. His first wife had passed away ten years earlier from cancer, and he had raised his two children into adulthood on his own. While he was working and taking care of his children, he felt he didn't have time for a relationship. Now that his kids were on their own, he met and married a woman twelve years younger. "Clarice is great, and I'm very lucky to have such an attractive wife," he said. "But even though I know she's attractive, I just don't have the urge to do anything sexual with her." He paused for a moment. "Or with anyone, for that matter," he added.
Jerry described his situation further. "It's like a part of me is switched off. Once in a great while we have sex, maybe once every month or two. I can get hard, but I have to really concentrate to stay hard, and it's a struggle. My other doctor gave me some of those erection pills—they did help me stay hard but didn't change my interest."
"How long has it been since you had a strong interest in sex?" I asked.
"I couldn't really tell you, Doctor. My first wife and I had an active sex life until we had kids, and then it changed a bit, like it probably does for everyone. But then she got sick, and I never really paid too much attention to sex until I met Clarice years later."
I asked Jerry what he hoped to achieve by his consultation with me, and he responded, "I actually don't want anything for myself. But Clarice deserves more from me. She's a younger woman, she took a chance on a guy like me with two kids already, and she deserves to have sex on a regular basis. She likes it, and she tells me she feels closer to me after it happens." Jerry shifted in his chair. "I'll tell you a story. Last Valentine's Day we went with three other couples up to this nice inn in Vermont for the night. We all had a great dinner, and then everyone joked about heading up to their rooms to have sex. When we got up to the room, I climbed into bed, turned off the light, and went to sleep. It was embarrassing."
Jerry's past medical history gave no clues as to what may have been causing his difficulties. Some medicines can cause sexual problems, but the only prescription medicine he took was for high cholesterol—a medicine that doesn't usually cause sexual problems. Depression can cause lack of sexual desire or performance, but Jerry had no history of depression. When his blood tests came back, however, it showed that his testosterone levels were low.
I started Jerry on testosterone treatment with gel. At first, he noted no changes in his sexual desire, and blood tests showed that his T levels had increased only into the lower range of normal. I then increased the dose of gel, and his blood tests showed excellent levels of testosterone, in the midrange of normal. Jerry reported that he started waking up with erections in the morning. "It's like seeing an old friend again," he said with some pleasure. This was a positive sign.
"Give it a couple of months now," I advised.
Two months later, Jerry returned with Clarice by his side. They made an interesting couple, Jerry his usual disheveled self and Clarice a petite, pretty woman who was well put-together.
"How are things going?" I asked, after Clarice and I had introduced ourselves.
They both smiled. "Great!" Jerry exclaimed. "Clarice says I'm like a teenager the way I'm after her all the time." Jerry looked over at Clarice and they seemed to share a momentary private joke. "I don't think it's that extreme," he said, "but we're having sex on a regular basis now, at least once or twice a week. And I think about sex again, even when we're not doing anything. I'd forgotten what that was like, but I remember that I used to do that all the time, before my first wife got sick."
"Have you noticed any other changes in Jerry since he started treatment?" I asked Clarice.
"Definitely," she replied. "It's hard to know whether it's the testosterone itself, or just one good thing leading to another, but Jerry seems happier. He jokes around with me in ways he only rarely did before. He makes decisions more quickly. For example, when I used to ask him what movie he wanted to see, he would usually just turn it around and ask me what I wanted to see. But now he'll tell me what he's interested in. It's like Jerry has emerged from his shell."
Clarice's description of the changes in Jerry was typical of what I hear from the partners of men treated with testosterone. Many times, men come in for a specific symptom, such as low libido or erectile dysfunction, and they evaluate the response to treatment by focusing only on those original symptoms. But subtle changes in how a man acts or the energy he gives off in day-to-day interactions may be less visible to the person himself, but obvious to the people around him. Often, the man will deny noticing any other changes with treatment, while his partner will turn to me and say with conviction, "Oh yeah, he's different."
One other point to make about Jerry's case. Although there can be a number of reasons why T levels can be low in men, the most common by far is the gradual decline in testosterone that accompanies aging. This doesn't mean that Jerry was old—some men will have normal T levels into their eighties. But it is often difficult to pinpoint the moment when libido changes or disappears. Slow changes can be difficult to notice, especially when they happen over many years and when there are major stresses going on in life. In Jerry's case, there was a period of many years when he was coping with the grief of his first wife's death and the challenges of raising his children alone. At some point during that stressful period, Jerry's testosterone levels likely dropped into the low range, but he didn't notice it because of everything else going on in his life. This is true for many men.
Low Energy, or "The Couch Speaks to Me"
I still laugh when I think of Richard's story. Like most physicians, I have my patients fill out a form before I see them on which they list their medical information, such as current medications, allergies, and prior operations. Near the top of the form is a line that asks, "What is your reason for seeing the doctor?"
In response to this question, Richard had written: "The couch speaks to me." I wasn't sure what this meant. When I entered the exam room, there was Richard, a tall, lanky guy, forty-six years old, who greeted me with a big smile and a shock of red hair hanging over his forehead, which he swept away with a big, calloused hand.
"So," I asked, curious, "what do you mean, 'The couch speaks to me'?"
"Doctor," Richard began, "I've always been a busy guy. I hold two jobs, not because I need the money, but because I like being busy. And on nights and weekends, I'm always in my shop in the basement, working on projects. Ever since I was a kid, I've been 'Go, go, go.' But over the last couple of years, every time I walk across my living room, I hear the couch call out to me, saying," and here Richard cupped his hands to his mouth, as if calling someone far away, "'Come! Lie down! Take a nap!' "
Richard grinned at me, pleased with his performance, and I couldn't help but laugh out loud. He went on, "Doc, taking naps in the middle of the day just isn't me. I'm not depressed, my life is great otherwise, I don't have any major stresses in my life. I just feel like there is something different about my body and my brain, and I'm wondering if it's low testosterone."
Richard denied having any other symptoms of low T. His erections were fine, his libido was strong, his mood was good and upbeat. The only thing he complained about was that he just didn't have the same energy level and drive to be busy that had defined him his whole life.
Sure enough, Richard's T levels came back low. I started him on testosterone therapy and saw him back in follow-up a couple of months later.
"How are you?" I asked.
"Doc," he replied, "the couch doesn't speak to me anymore. I'm cured."
Richard's story highlights the impact of low T on what we call energy or motivation or fatigue. Energy may sound like the opposite of fatigue, and motivation can be synonymous for energy in some circumstances, but many men make distinctions between these words in using them to describe how they feel. Another overlapping word and feeling is having a sense of vitality, a feeling of being alive. The loss of these can be due to low T, and all may resolve with treatment.
The subtlety of these feelings makes them hard to study. And sometimes the response to treatment may be more obvious to those around him than to the man himself. Many times I've heard the man's partner tell me, "There's something different about him. He just seems so much more ... alive."
Erectile Dysfunction
Samuel was a seventy-two-year-old, wiry man who saw me for erectile dysfunction. "I've been married for forty-four years to the same wonderful woman. Doc, she's as beautiful today as the day she became my bride. But for the last two years, I just can't get an erection that's firm enough to have sex anymore. My regular doctor gave me a prescription for all three of the erection pills out there, Cialis, Viagra, Levitra, you name it, and they all help a little bit, but not enough to make a difference."
I asked about his libido. "Oh, the desire is there, all right." He gave me a wink. "No problem in that department. And we've figured out other ways to stay physical, if you get my meaning, and I can still come. But I'm just never hard anymore. Used to be that I would wake up with a good erection from time to time or masturbate and get hard, but not anymore."
Samuel's normal sexual desire suggested that maybe low T was not the source of his erection difficulties, which we often call ED, for the technical term erectile dysfunction. Samuel had other reasons to have ED—hypertension and high cholesterol can both contribute to vascular disease, which in turn can cause ED. Samuel also took a number of prescription medications for those problems, which can sometimes contribute to ED. Given his age and medical conditions, it would have been reasonable to assume that Samuel's erection problem was due to blood vessel problems, specifically atherosclerosis. Tests performed in my office did indeed show some compromise of Samuel's blood vessels to the penis. In addition, blood tests showed low levels of testosterone.
When Samuel returned to discuss his test results, I explained to him that he had at least two possible reasons for his ED, one being poor blood vessels and the other being low T. Although normalizing Samuel's testosterone would be highly unlikely to improve his blocked arteries, it might still help his erections.
Samuel agreed and returned three months after beginning therapy. "Good job, Doc," he said when I entered the room. "The testosterone isn't a home run, but at least I get on base now," he joked. "What I've noticed since starting the testosterone is that I get aroused more quickly, and my penis gets harder than before. It's still not hard enough for me to have sex without any help. But the important thing is that the pills work now—just about every time. I can have sex again as long as I remember to take a pill."
As I mentioned at the beginning of the chapter, men may have one symptom of low T without having any of the others. This was true for Samuel. His libido, the hallmark symptom of low T, was unaffected by his low T levels, and he did not notice any change when his T levels were increased. Samuel's ED, though, had a component that was due to the low T. Men seem to have individual "thermostats" or thresholds, for each of the various symptoms of low T.
Recent studies in humans and animals show that there are receptors for testosterone in the corpora cavernosa of the penis, the chambers where erection takes place. These receptors send out chemical signals that are involved in the erection process. No wonder, then, that testosterone treatment has been shown to "rescue" erections in men with ED who have already had treatment with the erection-enhancing pills.
In one study of men who had failed full-dose treatment with sildenafil (Viagra), treatment of low T resulted in one-third of the men being able to have sex without any other medications at all, another third being able to have sex with testosterone therapy and the erection pills combined, and the last third were still unable to have sex. Testosterone can be an effective treatment for many men with erectile dysfunction.
Decreased Muscle Mass
Jack came to see me for a different reason. Now fifty-eight years old, he'd been an athlete his whole life, making it as a professional football player briefly in his twenties, then slimming down as a "fitness freak," in his words, for the rest of his life. He participated in marathons, cycling events, and whatever else he could find to test his body.
"I know what my body is capable of and how it responds to exercise," Jack told me. "For the last year or two, when I go to the gym after being away from it for a few months, I just can't build up the way I used to. Over the last eight weeks, I've been stuck with the same weight when I bench-press and can't move up. In the past, I would have been adding more weight every week or two."
"How would you like me to help you?" I asked.
"I'm not looking for miracles," Jack said, "and I'm not interested in being Superman. Or Schwarzenegger," he smiled wryly. "But it's important to me to be fit, stay fit. Right now, I'm feeling old, and I never felt that way before. If you can help me feel the way I think I should, that would be great. My primary care doctor tested my blood and told me my testosterone was in the low-normal range, but he wasn't sure what to do about it or whether it was causing my symptoms because I don't have any sexual problems at all. So he suggested I talk to you about it."
I ran through the various symptoms of low T, and indeed, Jack had none of them other than the feeling that he wasn't as vigorous as he once was and that his muscular response to exercise wasn't as good as it had been in the past. One other symptom he noted was that it took longer for his body to recharge after a heavy workout. When I looked at Jack's previous lab results, his total testosterone, the test used by most physicians, was just within the normal range suggested by the laboratory, but it was actually indicative of low T.
Jack started treatment with testosterone. He didn't like the gels, because he worked out so frequently that he was afraid he would sweat it off, so he underwent injections in my office every two weeks. Later he learned how to give himself injections in the thigh. I monitored his levels closely because the goal was to get him back into the normal range for men, not to get his levels up into the stratosphere, like bodybuilders and athletes using steroids for performance enhancement.
Jack was gratified with the results. "I'm OK again," he volunteered. "I can't do what I did when I was twenty-five years old, but then, I'm not twenty-five anymore. I've been moving up on my weights in the gym, and my muscles recover more quickly from the big workouts. The big thing is, I don't feel like an old man anymore."
When It's Not Low Testosterone
As can be seen from the stories of these men, testosterone treatment in men with low T can produce a fairly wide number of beneficial results. Let's be clear, though, that testosterone is not the solution to every symptom, nor does it work in everyone. After all, even men with completely normal levels of testosterone can have ED, low sex drive, or poor energy. Sometimes the cause of a man's symptoms is just life—stress, medical conditions, relationship issues, trouble at work.
Two of the common factors that may cause symptoms suggestive of low T are depression and medications. Alphonse's story underscores this nicely. Alphonse was a forty-four-year-old construction worker who came in with his wife, Sherry. When I asked Alphonse how I could help him, he turned to Sherry. "Why don't you tell him?" he suggested.
"Al was diagnosed with diabetes three years ago, and then he became depressed. He's better now, but we have two problems. One is that he has almost no interest in sex. We have sex every three months or so. The other is that we'd like to have a baby. I've been off the pill for four years, and we don't use anything else for birth control. But if we don't have sex, it's obviously hard for me to get pregnant."
Sherry continued, "We've been through a lot together. When we first started talking about having a child together ..." She paused and corrected herself. "When I first started talking about having a baby, Al didn't say no, but he didn't say yes. He seemed to be struggling with the idea, and I think part of what happened is that he didn't want to have sex with me because he wasn't ready to be a father. We've talked about it more over the last year or two, and now I think we're both ready. At least, Al seems ready. But we still almost never have sex."
(Continues...)
Excerpted from Testosterone for Lifeby ABRAHAM MORGENTALER Copyright © 2009 by President and Fellows of Harvard University. Excerpted by permission of The McGraw-Hill Companies, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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