What should you do? Learn as much as you can about your body. Stay calm. And think of medical knowledge as a jigsaw puzzle. Scientists know the outlines pretty well, but researchers are still struggling to make the smaller pieces fit into place. If you keep the big picture in view, you won’t go astray as you wait for the details to emerge.
Here is a guide to three current controversies that extend from birth to old age.
MALE CIRCUMCISION
Dating back more than 4,000 years, circumcision is the oldest operation in continuous use. It’s one of the most common operations in the United States, where it’s performed more than 1.2 million times a year. It’s also one of the fastest operations, taking just three to five minutes from start to finish. But it has also become one of the most controversial procedures.
Circumcision began as a religious rite, but it became routine medical practice in the United States about 100 years ago, when doctors believed it prevented disease. In societies where men practice good hygiene, however, the net gain is slight. Circumcision reduces the risk of inflammation and infection of the penis in adulthood, but hygiene is nearly as protective. Similarly, circumcision and good hygiene will both reduce the risk of cancer of the penis, which is rare in the United States. One benefit of the operation is a somewhat reduced risk of certain sexually transmitted diseases, both for men and their partners. But whether or not a man has been circumcised, safe sexual practices are the only effective way to prevent sexually transmitted diseases.
If the benefits of circumcision have been overstated by its advocates, its risks have also been exaggerated by its critics. Some parents worry about surgical complications. Fortunately, they are uncommon and are usually mild. Pain is another concern. Contrary to some cultural beliefs, the operation is painful. However, effective pain control is available in the form of local anesthesia administered in injections or creams. Sexual dysfunction is the biggest concern. Heart-wrenching testimonials notwithstanding, there is no reliable evidence to support the claim that circumcision impairs sexual function or satisfaction in either partner. A 2003 study used a battery of tests to compare penile sensitivity in circumcised and uncircumcised men; there were no differences.
Many medical decisions can be made over time, and many choices are subject to change. But whether to circumcise an infant is a question that parents must answer shortly after the birth of a son. Circumcision has health benefits, but the net gain is so small that parents may reasonably choose to forgo the operation. Religious convictions, cultural attitudes and personal beliefs are usually the determining factors; and many parents simply decide that a son should look like his father. If parents choose circumcision, they should be sure the procedure is performed by an experienced individual, that their son is healthy and that modern anesthesia is provided.
HRT FOR MEN
Aging is not for sissies. Among other indignities, an average guy will lose 12 to 20 pounds of muscle, 15 percent of his bone density and two inches of height en route to his golden years. His counts of oxygen-carrying red blood cells will also drop. And it’s no secret that sexual vigor tends to diminish with age.
A good diet and an exercise regimen that balances aerobics with strength training can keep muscles and bones remarkably strong. A healthy lifestyle can do more than medicines to prevent diabetes, high blood pressure and atherosclerosis–the diseases that underlie erectile dysfunction in about 50 percent of men over 75. But lifestyle changes take work. Many men turn to hormones for help. Is it wise?
Testosterone is essential for the development of male genitals during fetal life, it triggers the dramatic events of puberty and it is necessary for libido and fertility throughout maturity. The hormone also stimulates muscles, bones and red blood cells. Testosterone levels surge at puberty, peak at about 17 and remain high for the next couple of decades. But beyond 40, testosterone levels fall. Unlike the sharp drop in estrogen that women experience at menopause, the decline in testosterone is gradual, averaging just over 1 percent a year. One percent is not much, but by 70 or so, it adds up to a 30 percent decline.
Can supplementary testosterone turn back the clock? Most men have plenty of testosterone to spare, so levels remain within the normal range in at least 75 percent of senior citizens. Men who are truly testosterone deficient (hypogonad) should receive treatment. But even if your testosterone levels are normal, extra testosterone will boost your muscle mass and red-blood-cell counts.
That’s why so many competitive athletes abuse steroids. Prescription testosterone is much safer than the huge doses used by some jocks. But testosterone may have adverse effects on a man’s cholesterol and cardiovascular risk. It also stimulates the prostate, which may increases the risk of benign prostatic hyperplasia (BPH) and prostate cancer.
Should you join the more than 1 million men with normal hormone levels who are getting testosterone prescriptions from their doctors? Not yet. There just is not enough evidence that the possible benefits exceed the known risks. The same goes for other hormones. Testosterone is the most important male hormone, but there are other androgens. Dehydroepiandrosterone (DHEA) and androstenedione (“andro”) are weaker androgens that decline with age. Both are freely available without prescription as “dietary supplements.” DHEA is heavily promoted as an antidote to aging, and andro is touted to boost athletic performance. Careful studies have failed to show benefit from these preparations, and they do have potential risks. For safety’s sake, wait for more studies.
PSA SCREENING FOR PROSTATE CANCER
It sounds like a no-brainer: a safe, convenient, inexpensive blood test that can detect prostate cancer long before it causes any trouble. Unfortunately, it’s not that simple–and it’s a decision every man will have to face every year between the ages of 50 (in some cases, 40) and 75.
Prostate specific antigen (PSA) is a protein produced by every prostate gland, benign or malignant. The prostate secretes PSA into the ejaculate, where its job is to liquefy semen so sperm can swim to their intended target. But some PSA also enters the blood. Men with prostate cancer tend to have higher levels of PSA in their blood than healthy men. Most doctors use 4.0 ng/ml (nanograms per milliliters) as a cut-off. But since PSA values tend to rise with age, even in healthy men, other authorities use age-adjusted values. Can the height of the PSA value help estimate the likelihood of prostate cancer? Yes, but it’s only a rough guide. A perfect test would tell if a disease is present or not. Although the PSA is the best test for prostate cancer, it’s far from perfect.
In round numbers, about 20 percent of men with prostate cancer have normal PSA levels. At least two out of three men with high PSA levels do not have cancer: instead, their results have been elevated by some other condition such as benign prostatic hyperplasia (BPH), prostatic inflammation or a urinary-tract infection.
Most men would gladly trade two false alarms for one life-saving early diagnosis. But the value of early cancer detection is problematic for prostate cancer. Unlike many other malignancies, prostate cancer can have a long latent phase. Cancer cells can exist in the prostate gland for years, even decades, without causing harm. An American man’s risk of developing prostate cancer at some time in his life is about 30 percent, yet his risk of developing clinically important disease is less than 10 percent and his risk of dying from prostate cancer is only about 3 percent. In other words, two of every three prostate cancers are harmless, even if unrecognized and untreated. And since treatment often produces impotence and sometimes causes urinary incontinence, it may do more harm than good for some men. Despite all this information, it’s not yet clear whether PSA testing saves lives. Randomized clinical trials are the only way to find out if testing saves lives. The only trial that has been completed failed to show benefit. Better studies are underway but will take years to complete. Until then, the only honest answer to the crucial question is “maybe.”
The American Cancer Society (ACS), the American Urological Association (AUA) and the American College of Radiology (ACR) recommend that doctors offer annual PSA testing to every man above 50; they also call for yearly testing to start at 40 (AUA) or 45 (ACS) for men at increased risk, including African-Americans and men with family histories of prostate cancer. But the U.S. Preventive Services Task Force and the American College of Physicians say men should be advised of “the known risks and uncertain benefits” before they decide to be tested.
The PSA is the best way currently available to detect prostate cancer in its earliest, most curable form. Still, keep in mind that more men die with prostate cancer than from it; that the test gives false positive and false negative results, and that early diagnosis and aggressive treatment may have substantial adverse effects. Talk it over with your doctor. If you are married, you may choose to discuss it with your wife. Think it over calmly. Until research puts an end to the PSA controversy, your own instincts will do just fine.
