Recently, an article in the New England Journal of Medicine described the case of a man whom had visited his doctor and expressed concerns about feelings of decreased energy, inhibited sexual pleasure and erectile function, and a decreased ability to play sports. The man’s blood test revealed that his testosterone level was decidedly below the normal range for men his age, and two treatment options were presented: one in favor of testosterone replacement therapy, and one recommending against it.
Arguments both for and against hormone replacement therapy were presented, and the authors asked the medical community which option was best for the patient.
Given the information presented in the article, I believe that the patient should absolutely receive a trial of testosterone therapy. I respectfully disagree with Dr. Anawalt. I have treated men with suboptimal testosterone levels for approximately 8 years. Many men like Martin with symptoms of decreased energy, stamina, sexual pleasure, and erectile function and suboptimal testosterone levels like Martin’s derive enormous benefit from testosterone therapy. With testosterone therapy Martin will more than likely experience more energy, improved muscle and bone mass, an improved sense of well- being and improved sexual function, including libido and erections. Dr. Anawalt mentions side effects of testosterone including erythrocytosis which can easily be managed (see more below) and infertility. I highly doubt Martin is overly concerned with his fertility at 61 years old, although that is a point to mention to the patient.
Dr. Anawalt also mentions that therapy is expensive and inconvenient. This doesn’t have to be the case. Testosterone injection therapies have been used for many years to achieve results that are in many cases superior to transdermal gels and are much less expensive. Additionally, injection therapies only need be administered weekly. There are even newer injection therapies that can be used less frequently. One must consider all of the available treatment options, not only the most common because of the push received from pharmaceutical sales reps.
Below are excerpts from my Huffington Post blog written earlier this year in response to to concerns over testosterone therapy.
The current negative perceptions about testosterone therapy run counter to a large body of literature of the last 20 years that supports testosterone treatment as an important therapy that can improve cholesterol levels, decrease blood sugar levels, reduce body fat and increase lean muscle mass, all factors that would reduce the risk of heart disease. A new review article was published in December 2013 in the esteemed Journal of the American Heart Association with the goal of providing a comprehensive review of the clinical literature that has examined the associations between testosterone and cardiovascular disease. Well over 100 studies were reviewed, and the authors concluded that low levels of testosterone are associated with higher rates of mortality and cardiovascular- related mortality, higher rates of obesity and diabetes. Additionally, the severity of disease correlated with the degree of testosterone deficiency. Testosterone therapy has been shown to relax coronary arteries and improve ability of patients with congestive heart failure to exercise. Testosterone therapy has been shown to lower blood sugar in diabetics and to lower body mass index in obese patients. Finally, studies have associated lower testosterone levels with thicker walls of some of the major blood vessels. This thickening increases the risk of atherosclerosis thus leading researchers to conclude that low levels of testosterone increase the risk for atherosclerosis. All of these factors point to the conclusion that optimal testosterone levels decrease the risk of cardiovascular disease.
Some “experts” and physicians have been supporting warnings against testosterone therapy and are starting to educate their patients on possible increased risks of heart disease. Doctors are the ones who need more education here. Physicians should be educated on the possible issues they may encounter with patients on testosterone therapy, including higher levels of red blood cells and elevated levels of estrogen. Physicians should monitor their patients’ blood cell counts and estrogen levels on testosterone therapy to assess for these risk factors for cardiovascular disease. If a patient has a high red blood cell count, the dose of the testosterone can be decreased or the patient can be sent for blood donation to reduce the high red blood cell count and thus any increased risks of clots or heart attacks. Additionally, high estrogen levels may increase the risk of heart attack and stroke. There are medications that can be prescribed to control high estrogen levels and keep estrogen in the proper, low risk range. These precautions need to be used when prescribing testosterone therapy and studies need to be done reflecting results of testosterone use when these precautions are followed.
It is my sincere hope that doctors will understand what testosterone therapy can do to help men like Martin and that it can be done safely when it is monitored properly. The mass discontinuation of estrogen replacement therapy for women has been a huge disservice to them (see http://news.yale.edu/2013/07/18/women-hysterectomies-estrogen-may-be-lifesaver-after-all) as will avoidance of testosterone therapy for men if that is the route that physicians choose.
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