Testosterone Replacement

Living Well in Myanmar

History reveals why doctors and patients should be wary of claims that testosterone replacement improves health

Several months ago an expatriate living in Yangon came to my clinic to follow-up on testosterone replacement therapy that he had started in the US. He had gone to his doctor with complaints of tiredness and decreased libido, which he thought might be due to low testosterone. The patient said he hadn’t considered the possibility of suffering from low testosterone until he saw an announcement about this condition in a men’s health journal.

I was surprised that his doctor provided treatment. Using a blood test to screen men for low testosterone is not considered routine clinical practice. Furthermore clinical guidelines for diagnosis and treatment are lacking.

Then two weeks ago, during a trip to California, I came across several radio and print advertisements urging men to get checked for “Low T”. These were ads for clinics set up specifically to check testosterone levels and, subsequently, prescribe and sell testosterone replacement in the form of injections, skin patches or pellets that are implanted into the buttocks. I presume business is brisk, since decreasing testosterone levels are a normal part of aging, and many older men will have low testosterone levels that don’t mean they are sick.

The problem with these clinics is that having mildly decreased testosterone has not been proven to harm health. Medical providers sometimes make the assumption that if a hormone in the body gets too low it needs to be replaced in order to preserve good health. We know this to be the case for a hormone like thyroid: Replacing it can improve health and even be life saving.

However, Western medicine has not provided good research to defend the assumption that testosterone needs to be supplemented just because it’s low.In fact, history provides us with a strong example of how hormone replacement therapy conducted without a good understanding of long-term effects can have unintended consequences.

In the 1980s and 90s, doctors routinely prescribed estrogen and progesterone therapy to women when they reached menopause. The intent was to treat immediate symptoms such as hot flashes and mood swings, as well as address perceived long-term health threats such as bone loss and heart disease.

Then along came the Women’s Health Initiative in 1991, a research study that enrolled 160,000 postmenopausal women in the United States. By 2002 the evidence was clear that women on hormone replacement therapy were actually at increased risk for cardiac disease, as well as breast cancer, stroke and pulmonary embolism. The impact on health practice was immediate – doctors cut way back on new hormone prescriptions, and today we start women on hormone therapy only if their symptoms are severe and then only for the least amount of time possible.

Clearly the possibility exists that we will make a similar mistake with testosterone in men. Medical advocates of testosterone note that replacement therapy is associated with an increase in lean body mass, decreased fat mass, increased bone density, improved mood and enhanced libido and sexual function. However, “associated” is the key word. Research does not show causality, meaning we don’t know for sure that hormone supplements are the immediate cause of the improvements. Furthermore, and most importantly, we don’t have anything like the Women’s Health Initiative to teach us what the effect of testosterone will be if taken for many years.

It should be noted that certain diseases such as cancer, diabetes, hyperthyroidism, and hyperprolactinemia can cause extreme decreases in testosterone. In these situations, because the short term effects are so significant, it may be reasonable to replace the hormone without a good understanding of its long-term effects.

In a worrisome development, a recent study in the Journal of the American Medical Association evaluated 8709 men with an average age of 63 and low testosterone levels. They found that heart attack, stroke or death occurred in 26pc of those who received replacement therapy and 20pc of those who did not. While the difference is small, it is significant, and clearly suggests we should be taking a cautious approach to this topic.

The current state of testosterone replacement understanding seems very similar to where we were with women and estrogen/progesterone 10 years ago. Direct-to-consumer advertising is persuading patients to seek relief for ill-defined symptoms and pressuring doctors to pursue treatment in the face of real concerns about long-term harm.

gelsdorfMD@gmail.com  © Christoph Gelsdorf 2013