Book Review – Testosterone for Life by Abraham Morgentaler, MD
Written by Carol Petersen, RPh, CNP – Women’s International Pharmacy
Dr. Abraham Morgentaler is associated with the Harvard Medical School, and has studied and published on the effects of low testosterone and its treatment. His book Testosterone for Life summarizes testosterone’s many important roles in the body, emphasizing the importance of diagnosing and treating a testosterone deficiency for optimizing health and well-being.
Dr. Morgentaler identifies the many benefits of treating low testosterone, including:
- Increased muscle mass
- Decreased body fat
- Increased bone density
- Increased “mojo”
- Increased libido and sexual interest
- Reduced erectile dysfunction (ED)
- Possible positive effects on the cardiovascular system, including lowering cholesterol and LDH
- Possible positive effects on longevity
The lab evaluations Dr. Morgentaler uses to diagnose and monitor treatment of low testosterone are:
- Total testosterone: less than 350 ng/dl is considered low
- Free testosterone: analog method – less than 15 pg/ml is considered low
- Luteinizing hormone (LH):
- A low level raises the possibility of pituitary or hypothalamus problems
- A high level indicates the testicles cannot produce testosterone
- A “normal” level is common with aging and the associated decline of testosterone
- A high level can cause low testosterone; a tumor should be suspected
- Hematocrit or hemoglobin:
- Low testosterone can produce anemia
- Treatment can produce an abnormal accumulation of red blood cells, especially with injectable rather than topical testosterone, in which case the patient can donate blood, lower doses, or stop treatment; monitoring should continue during treatment
- Dr. Morgentaler promotes getting a baseline to confirm that it is not already too high, and he also biopsies all new patients before treatment
- Bone density:
- Again, to get a baseline and monitor
Dr. Morgentaler discusses a wide range of treatments, including their pros and cons, and his recommended dosages. His summary of testosterone therapies includes:
- Injectables include cypionate and enanthate, which can be used interchangeably. Dr. Morgentaler recommends an injection every two weeks, but some might need it every 7-10 days, and some stretch it out a little longer than the 14 days. He usually uses 200 mg but has gone as high as 400 mg every 2 weeks. Some men need to get their testosterone level up to 600-650 ng/dl before they feel better. Blood tests should be done half-way into the treatment cycle (usually 7 days). The FDA is considering a long-acting injectable product (Nebido®), which can last up to 10 weeks.
- Patches usually only reach into the lower ranges of normal, so men don’t absorb much testosterone at all. There are a lot of problems with skin irritation (as much as 44% in 1 study).
- Gels increase both total and free testosterone levels. Gel absorption is better than patches, but approximately 15-20% of patients still do not absorb gels well. The gels must be used at least daily, and the patient should not bathe or shower for at least 2 hours after application. Dr. Morgentaler may use as much as 10 gm. He believes that there is very little problem with transfer of the hormone on the skin to other people. The product Testim® has an odor that some patients find objectionable.
In Testosterone for Life, Dr. Morgentaleralso comments on treatments that are not prescribed as often, such as:
- Creams are available through compounding pharmacies, but Dr. Morgentaler does not like to recommend non-FDA approved products. However, he has done testing on men using creams and they were achieving reasonable levels.
- Implantable Pellets such as Testopel are a treatment that is easy to administer because they only need to be applied every 3-6 months.
- Buccal Pellets such as Striant are applied to the gums and stay there all day, to be replaced every twelve hours. This type of treatment is helpful for patients who have sensitive skin.
- Pills are available but Dr. Morgentaler advises against using testosterone pills because of liver toxicity (he is most likely referring to the synthetic analogs). He mentions that testosterone undecanoate (Andriol) is probably okay. However, several doses a day must be used and optimal levels may not be achieved.
- Clomiphene and anastrozole can stimulate LH and, in turn, result in more testosterone production, according to Dr. Morgentaler. However, with this type of treatment young men can develop excellent testosterone levels but still see no clinical improvement in their testosterone activity. This is the only treatment that stimulates sperm production; all other testosterone supplements will inhibit sperm production.
- HCG, or human chorionic gonadotrophin, requires injections 3 times per week and mimics LH. The use of HCG is usually limited to infertility patients or those who have not properly undergone puberty.
- Supplements such as ginseng and horny goat weed, Dr. Morgentaler claims are useless for raising testosterone levels, and he suspects that some of these supplements may contain Viagra.
- DHEA might play a part in testosterone therapy, but Dr. Morgentaler has not seen any substantial increase in testosterone levels.
While Dr. Morgentaler’s review of testosterone treatments is exhaustive, many professionals may take issue with his attitude about compounding (myself included). Other lapses in this book include his dismissal of statins having a negative effect on testosterone production (despite much research that suggests otherwise), and there is almost no discussion about estrogens and their effects on testosterone production and treatments. That topic could be another whole chapter in itself.
Perhaps the most interesting (and potentially controversial) nugget in Testosterone for Life is the research and background on the commonly held belief that testosterone increases prostate cancer risk. Dr. Morgentaler not only went back to determine the origins of that belief, but has demonstrated and published that it is wrong! He has not only treated men with a history of prostate cancer, but also daringly treated a few with active (but not otherwise treated) prostate cancer—and he has the data to back it up. Dr. Morgentaler’s book includes great detail on this topic and he will be a great resource for anyone looking for specifics about the relationship between testosterone therapy and prostate cancer.