If you watch much TV, you know all about “Low T.” And, if you’re a male, you have undoubtedly decided that you have it.
Low T, of course, stands for low testosterone, the male sexual hormone that, among other things, affects sexual functioning, bone and muscle mass, fat distribution and energy level.
Male hypogonadism, a condition involving inadequate production of testosterone, is sometimes present at birth or develops later in life as a result of an infection or injury. The effects can be serious, and, as a result the Food and Drug Administration has approved a number of products that have been proven effective at improving testosterone levels.
Oral testosterone is available but, if used over the long term, could have negative effects on the liver. Other testosterone replacement products include skin patches, gels, mouth patches, implants and injections.
Very effective marketing campaigns have made American males increasingly aware of these products and willing to talk to their doctors about them. As a very happy young male, recently treated with one of these products, says on a TV ad, “It was a number, not just me.” He learned his number and turned it up. Now he has a stronger sex drive, more energy and a better mood.
Another ad focuses on body fat, muscle mass, sexual performance and satisfaction.
The Low T quiz in a print ad includes questions about less strong erections and deterioration of work performance and ability to play sports.
Low T Products: Higher Sales
It’s easy to understand why men would become intrigued by these products and willing to give them a try. From 2001 to 2010, hormone use by middle-aged and older males in the United States increased fourfold. Today, more than four percent of males age 60 and over use testosterone products.
Except for the disclaimers made in the ads, testosterone replacement products are generally considered safe. Yet several recent studies have indicated some potentially serious risks that have not yet been fully examined.
One of the claims made for testosterone replacement is that it may reduce the risk of heart disease. This is based at least in part on the hormone’s positive influence on body weight, muscle mass, insulin sensitivity and blood sugar control.
On the other hand, some recent studies have suggested some serious heart risks associated with use of testosterone replacement–at least for some patients.
A study of U.S. veterans [Journal of the American Medical Association, November, 2013] found that those who took testosterone replacement therapy had a 30 percent higher risk of heart attack, stroke or death compared to subjects with a similar deficiency who did not receive extra testosterone.
A more recent study [PLoS ONE] found a two-fold increased risk of heart attack in men aged 65 and over during the first 90 days after initiating testosterone replacement. For younger men with a history of heart disease, the risk was two to three times greater.
The above were prospective studies that do not prove cause and effect. However, a randomized controlled study conducted by the National Institute on Aging was stopped early [2010] because of the higher frequency of heart-related events in subjects assigned to take testosterone.
Based on these and other studies, the FDA recently announced that it would review the safety of testosterone replacement therapy. “At this time,” the announcement stated, “FDA has not concluded that FDA-approved testosterone treatment increases the risk of stroke, heart attack, or death.” Patients should not stop taking prescribed testosterone products but should discuss individual risks and benefits with their physicians.
Testosterone is an important hormone, and the approved treatments are for use in men who “lack or have low testosterone levels in conjunction with an associated medical condition,” the FDA said.
It’s well known that testosterone levels decrease with age–about one percent a year after age 30. And this decline may well be a factor in symptoms such as decreased sexual drive, softer erections, changes in body composition and lower energy levels. These are also symptoms associated with what is considered normal aging so it’s not at all clear that low testosterone is a major cause.
Among older males tested in the Baltimore Longitudinal Study of Aging, 30 percent of those age 60 and over and half of those age 70 and over had total testosterone levels lower than 325 nanograms per deciLiter.
Normal testosterone is defined as 300 to 900 ng/dL, but that is a broad range, and there are many variables that can influence the number. In most men, levels vary from day to day and even hour to hour; they are generally highest in the morning.
In the Massachusetts Male Aging Study, more than half of men found to have low T in the afternoon had normal levels when tested in the morning. Chronic medical conditions, medications and nutritional deficiencies can also affect the number.
The European Male Aging Study recently proposed a definition of low testosterone syndrome based on a complete analysis of symptoms, not just numbers. The Endocrine Society recently released guidelines stating that:
• only men with hypogonadal symptoms should be evaluated for possible testosterone deficiency, and
• the diagnosis should be made only after at least two morning tests show an unequivocally low testosterone level.
For a young male with true symptoms of hypogonadism, a diagnosis should be relatively easy to make. For an older male with somewhat vague symptoms, the risk/benefit ratio of therapy is by no means clear cut.
Studies have consistently found improvements in muscle mass, body composition and strength in older males given testosterone therapy. These are desirable, but these same studies have failed to show conclusive evidence of better physical function, fewer falls or improved cognitive skills.
In addition to the potential risk of heart attack, stroke and death, testosterone therapy may contribute to sleep apnea, skin reactions and benign enlargement of the prostate. Men at risk of prostate cancer are advised to avoid these products.
At any age, low testosterone is common among men who are overweight, don’t exercise and eat a poor diet. Simple changes in diet and exercise patterns can reduce that pot belly and help you get a stronger sex drive and more energy for work and play–all the benefits and none of the risks of testosterone therapy.
REFERENCES:
Shehzad Basaria, M.D., “Testosterone therapy in older men with late-onset hypogonadism,” Endocrinology Practice, 2013;19(5):865-863.
Henry R. Black, M.D., “When men want testosterone, show them the evidence,” Medscape Cardiology, January 24, 2014.
“Erectile dysfunction: testosterone replacement therapy,” MedicineNet.com, edited by John M. Baird, M.D., FACS, January 1, 2007.
“FDA investigates the safety of testosterone drugs for ‘Low T,” HealthlineNews, February 4, 2014.
“Is testosterone replacement therapy right for you?” WebMD Medical Reference, reviewed by Brunilda Nazario, M.D., August 29, 2012.
Mayo Clinic Staff, “Sexual health,” MayoClinic.com, April 1, 2014.
Mayo Clinic Staff, “Male hypogonadism,” MayoClinic.com.
Matt McMillen, “Low testosterone therapy: risks and benefits, WebMD, reviewed October 16, 2012.
Nancy A. Melville, “Testosterone testing, treatment soar despite uncertainties,” Medscape Medical News, January 10, 2014.
Lisa Nainggolan, “Endocrine Society calls for longer, larger studies on testosterone,” Medscape Medical News, February 20, 2014.
Michael O’Riordan, “FDA now investigating CVD risks with testosterone therapy,” Medscape, January 31, 2014.
Roni Caryn Rabin, “Weighing testosterone’s benefits and risks,” New York Times, February 3, 2014.
U.S. Food and Drug Administration, “Safety announcement, January 31, 2014.
Charles P. Vega, M.D., “Putting the ‘T’rouble in testosterone therapy?” Medscape Family Medicine, January 30, 2014.
06/23/2014
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