Low Testosterone Diagnosis and Treatment, the  Male Andropause

Beginning around age 50, there is a decline in major hormone levels in both men and women with associated symptoms.  For women this is called Menopause, and for men, it is called Andropause.  For men, the decline is gradual and symptoms can be ignored for awhile.  However, by the time men reach their seventies, most men have 30 to 50 percent less testosterone than they had when young. This causes muscle weakness, reduced libido, depression and loss of mental acuity.   These symptoms are reversible with testosterone therapy and millions of men over age 50 are now using testosterone for this reason. 

Testosterone Levels Decline with Age:

Testosterone Therapy is Increasing

About 2 million prescriptions for testosterone were written in 2002. This represents a 30% increase from 2001 and a 170% increase from 1999. There has also been a 500% increase in prescription sales in the past 10 years. The rise in prescriptions may be in part due to the increasing recognition low testosterone in ageing males (or andropause). 

Medical studies suggest an association of low testosterone with increased morbidity and mortality.  For example, there is a higher prevalence of depression, coronary heart disease, osteoporosis, fracture rates, frailty and even dementia with low testosterone states. (1A)

You might ask the question: Why isn't testosterone therapy accepted by my doctor and the conventional medical system?  Of course, there are many reasons for this.

Fake Testosterone in The 1940s and 1950s

A major reason is the debacle in the 1940s and 1950s, when patent medicine companies sold a synthetic "hormone" called methyltestosterone, pawning it off as the real thing.  After a few years of taking this chemical form, which does not exist in the human body, many of the men developed liver cancer and heart disease. The experts proclaimed that "testosterone therapy" was dangerous, so testosterone research died and didn't wake up until the late 1980s with the use of safer, bio-identical testosterone.

BioIdentical Testosterone

Bad Reputation from Abuse in Sports

Testosterone has a terrible reputation. After all, it is an anabolic steroid.  We all know about overambitious athletes taking illegal steroids to gain a competitive edge.  Following their example, 7 percent of male high school seniors have taken anabolic steroids. This is an example of tragic self induced hormone overdose, but it has nothing to do with the subject of testosterone therapy for the decline associated with aging which has important health benefits.   In response to the sports abuse issue, Congress, in its ultimate wisdom, made Testosterone a Controlled Substance just like cocaine and morphine.  Illegal use penalties are severe, with 5 years imprisonment for any doctor who prescribes testosterone improperly.  No wonder doctors are reluctant to prescribe it.

Institutional Medicine is Opposed to the Idea

In November 2002, the Institute of Medicine declared that "existing scientific evidence does not justify claims that testosterone treatments can relieve or prevent certain age-related problems in men."  I disagree with this statement.  There are literally dozens of studies in the medical literature showing health benefits and safety of testosterone therapy.  I believe that a normal level of testosterone, sustained for a lifetime, is one of the most important ways for men to maintain good health.

Safety Regarding the Prostate:

Does Testosterone Therapy cause Prostate Cancer?  The answer is NO and is clearly found in the medical literature.  Dr. Rhoden, in the January 2004 issue of the New England Journal of Medicine, reviewed 72 medical studies and found no evidence that testosterone therapy causes prostate cancer. (1)   In fact, they note that prostate cancer becomes more prevalent exactly at the time of a man's life when testosterone levels decline.

Does Testosterone cause Prostate Trouble? 

Dr. Perchersky published a study in the International Journal of Andrology (2002), which examined men with low testosterone levels (2). He looked at multiple parameters, including prostate volume, PSA, and lower urinary tract symptoms like frequency and urgency. Of the 207 men studied, 187 responded favorably to testosterone treatment. These 187 all showed improvement in every parameter measured: Their prostate glands all decreased in size, their PSA numbers went lower, and frequency, urgency, dribbling, and getting up at night all improved. This study indicates that, far from causing prostate trouble, testosterone is actually beneficial for the prostate gland in the vast majority of cases.

A recent study by Leonard Marks, MD in JAMA again shows safety of testosterone therapy.  "No treatment-related change was observed in prostate histology, tissue biomarkers, gene expression, or cancer incidence or severity. Treatment-related changes in prostate volume, serum prostate-specific antigen, voiding symptoms, and urinary flow were slight." (2A)(2B)

Benefits of Testosterone :

Benefits include positive effects on mood, energy levels, verbal fluency, strength, increased muscle size, decreased body fat and increased bone density.  There is also an anti-depressant effect.

Benefits of Testosterone: Heart and Circulation

Dr. S. Dobrzycki studied men with known coronary artery disease and showed they had significantly lower levels of testosterone (J Med Invest 2003).(3)  He also showed that lower testosterone levels was associated with reduced pumping ability of the heart. 

Dr. C.J.  Malkin showed that testosterone therapy reduced the risk of death from abnormal heart rhythms (arrhythmias).  This was published in the American Journal of Cardiology in 2003 (4). Dr Malkin also reported that Testosterone acts a protective factor against atherosclerosis and plaque formation in arteries    (J Endocrin 2003).

Dr. Gerald Philips at Columbia University, and  Dr. Joyce Tenover of the University of Washington also showed that low testosterone correlates with increased heart disease. These are only a few of the many recent articles.  Dr. Eugene Shippen presented an impressive study at a recent meeting I attended, in which testosterone therapy was used to successfully reverse diabetic gangrene of the lower legs and avoid amputation in many cases. 

Testosterone Improves Cognitive Abilities:

Dr. Cherrier has an impressive array of studies which show testosterone improves cognitive and verbal abilities in men. (5)(6)(7)(8)

Adverse Side Effects of Excess Testosterone.

Adverse side effects from excess Testosterone administration listed in the medical literature are: sleep apnea, breast enlargement, testicular atrophy, excess blood count (polycythemia), and acne.  Prostate issues such as possible stimulation of benign growth of the prostate (BPH) and worsening of urinary symptoms and stimulation of pre-existing prostate cancer growth are also included in this list. With careful monitoring of clinical and laboratory parameters, and keeping Testosterone levels within the normal range, these side effects can be avoided or minimized.

Monitoring of Testosterone Therapy:

Initially, a careful history and physical examination is required, as well as a testing panel which includes not only free testosterone levels, but also many other important parameters.   As usual, it is important to work closely with a knowledgeable physician who is readily accessible and who can monitor adverse side effects and adjust treatment. 

Recommended Reading:

The Testosterone Syndrome by Eugene Shippen, M.D.

Maximize Your Vitality and Potency for Men Over 40, Wright Jonathan V, Lenard L., Smart Publications, Petaluma, California, 1999
 

Testosterone and Andropause: the feasibility of testosterone replacement therapy in elderly men.
Lund BC, Bever-Stille KA, Perry PJ.
Pharmacotherapy. 1999 Aug;19(8):951-6.  link

Case Scenarios in Androgen Deficiency. McCullough, Andrew MD, Rev Urol. 2003; 5 (Suppl 1): S41–S48.   Link

References:

(1A) Salazar, J, Risks of testosterone replacement therapy in ageing men. Summary Expert Opinion on Drug Safety. November 2004, Vol. 3, No. 6, Pages 599-606

 
(1) Rhoden, E.L,  Risks of Testosterone-Replacement Therapy and Recommendations for Monitoring Ernani Luis Rhoden, M.D., and Abraham Morgentaler, M.D. NEJM Volume 350:482-492 Jan 29, 2004.

(2) Perchersky AV et al. "Androgen administration in middle-aged and aging men: effects of oral testosterone undecanoate on di-hydrotestosterone, oestradiol, and prostate volume." International J Androl 2002; 25(2): 119

(2A) Marks, Leonard S., Effect of Testosterone Replacement Therapy on Prostate Tissue in Men With Late-Onset Hypogonadism A Randomized Controlled Trial. , MD  JAMA. 2006;296:2351-2361.

(2B) Press Release for JAMA , Leonard Marks MD article

(3) Dobrzycki S et al. "An assessment of correlations between endogenous sex hormone levels and the extensiveness of coronary heart disease and the ejection fraction of the left ventricle in males." J Med Invest 2003; 50(3-4):162-169.