Testosterone Worries

There is no doubt that we are a testosterone-obsessed culture. And not just in sunny California, where I live. Who hasn’t seen those “Low T” ads nightly on the tube: Falling asleep after dinner? Feeling grumpy? Low energy? Losing strength? Sex drive slipping? Is testosterone really the Holy Grail that it’s been pumped up to be?

Testosterone Truths

As a clinician who prescribes testosterone all the time, the honest truth is that it’s a sticky wicket. The facts about what it can and can’t do are entirely unclear at this time. On top of this, the Food and Drug Administration (FDA) just announced that it is reexamining the safety of testosterone treatment after several recent studies linked it with an increase in heart problems.
Honestly, I’m a big believer that, in the right patient, testosterone replacement can put gas back in the tank of men who have been running on water. The truly hypogonadal man sees great benefit when T is replaced, with quality of life changes that are no less than spectacular. But is it the panacea for long life in everybody?

Testosterone as Elixir

One study about testosterone that has always impressed me was conducted in U.S. war veterans. The research looked at the mortality rates (death rates) in men over 40 years of age based simply on baseline testosterone levels. Importantly, no one in the study received testosterone replacement. The results showed that death from all causes was 88% higher in men with clinically low testosterone levels (<300 ng/dl) compared to men with normal levels. This suggested to me that although men with low testosterone levels are not more likely to die from any particular disease, they may actually “wear out” faster in general than men with normal testosterone levels.

Testosterone as Poison

What spurred on the FDA to make their recent statement were three recently published papers that looked at how men fared after receiving T replacement. In one study, 209 older (>65 years), community dwelling men with lots of chronic disease were given T replacement (or not) and followed for 6 months. Although real improvements were noted in muscle strength with T-replacement, this group of men was also noted to have higher rates of cardiovascular events such that the study was terminated early.
Two other studies may also have helped to flip the switch for the FDA: One study examined men with existing heart disease who were also given T-replacement and observed a 2-fold increased risk of heart attacks in the year following T-therapy relative to before T-therapy. Another report looked at death rates, heart attacks and strokes in men with suspected heart disease who were also put on T-replacement and observed a 30% increase in cardiac events in the T-treated men relative to untreated men. Again, both of these studies included older men with chronic heart conditions at baseline.
So OK, maybe we need to take a second-look at whether testosterone therapy can improve lifespan in men with preexisting heart conditions. Maybe such cases represent the classic story of “too little, too late.” Perhaps testosterone replacement in younger and “healthier” hypogonadal men prevents the later development of heart disease and actually increases longevity. We simply don’t know the truth at this point. My wager is that it lies somewhere in the middle and that time and good science will sort all this out. Randomized controlled trials can work wonders in this regard and have great potential to inform us who should and shouldn’t get this easily vilified hormone. For the time being, however, it makes no sense throw out the baby with the bathwater.
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