If you’re an older man thinking about testosterone therapy to improve your mood, energy and sex drive, there’s an important distinction to be made: Do you actually have low testosterone levels, confirmed by blood tests? Or do you have normal or low-normal testosterone levels but want to try treatment anyway?
Among men who have genuinely low testosterone — officially called hypogonadism but also known as “low T” — and are experiencing certain symptoms, testosterone replacement may help. Fatigue, increased body fat, reduced sex drive and erections, difficulty concentrating and other symptoms could be signs of low testosterone.
However, older men with normal testosterone levels won’t find a burst of youth from testosterone treatments. Prescription testosterone isn’t really helpful in these cases, research suggests, and may expose men to unnecessary health risks.
[See: The Scary Side Effects of Testosterone Replacement Therapy.]
Testosterone Basics
Testosterone is a male hormone, or androgen, largely produced in the testicles. With effects on bone density, muscle size and strength, body fat distribution, facial and body hair, sperm production, sex drive and red blood cell production, testosterone plays multiple roles in maintaining men’s health.
Testosterone levels shift throughout males’ lives. In puberty, which generally occurs in boys between 10 and 14, testosterone production increases. From its peak levels in adolescence and early adulthood, testosterone gradually declines about 1 percent a year after a man reaches roughly 30 to 40 years old.
According to the Endocrine Society, the normal total testosterone range is about 265 to 915 nanograms per deciliter for younger men ages 19 to 39. Guidelines discourage doctors from prescribing testosterone unless blood levels are clearly low. In the absence of symptoms in men ages 65 and older, low testosterone levels alone shouldn’t routinely lead to prescribing testosterone therapy, according to the society’s recommendations.
Tide Turning
Following an earlier surge in testosterone treatment spurred by heavy marketing, doctors today are writing fewer testosterone prescriptions.
In 2013, a study encompassing insurance prescription data on more than 10 million men ages 40 and older from 2001 to 2011 was published in JAMA Internal Medicine. Over that decade, androgen replacement therapy — testosterone prescribed in the form of topical gels, skin patches, pills and injections — more than tripled.
Then the trend reversed. Testosterone prescriptions for U.S. men ages 30 and older decreased by 48 percent overall from 2013 to 2016, according to findings published July 10, 2018, in JAMA after researchers revisited the database.
In the five-year period between studies, findings on possible heart attack and stroke risks from testosterone treatment appeared in several high-impact medical journals. In October 2016, the Food and Drug Administration approved changes to testosterone labeling to highlight the potential for heart-related side effects and mental health/abuse risks of testosterone products.
About one-quarter of men in the first study did not undergo any testing of their testosterone levels, says lead author Jacques Baillargeon. “We suspect, based on our previous study, that there were a lot of men who were not hypogonadal who were on testosterone therapy,” says Baillargeon, a professor of epidemiology in the department of preventive medicine and community health at the University of Texas Medical Branch at Galveston.
To the extent that men with normal testosterone are less likely to be treated than before, “that’s probably a good thing,” Baillargeon says. “But, I would add: If there are a substantial number of men with clear hypogonadism and they are foregoing treatment — that is potentially concerning.”
[See: The Real Sperm Killers.]
Mixed Findings
In one study, known as TEAM, or Testosterone’s Effects on Atherosclerosis Progression in Aging Men, men ages 60 or older were randomly assigned to receive either testosterone or placebo gel packets over a three-year period. Atherosclerosis, or plaque buildup in coronary arteries, did not appear to worsen in men receiving testosterone, researchers found. On the other hand, “sexual desire, erectile function, overall sexual function scores, partner intimacy and health-related quality of life did not differ significantly between groups,” researchers also concluded.
A coordinated group of studies called the Testosterone Trials set out to fill the information void. Sponsored by the National Institutes of Health, these seven, double-blinded, controlled studies included nearly 800 men, whose average age was 72, with confirmed low testosterone.
Essential findings were summarized in the March 7, 2018, issue of the journal Endocrine Reviews. For older men with low testosterone, one year of testosterone treatment led to the following results:
— All aspects of sexual function improved.
— Walking distance improved by a small amount.
— Vitality did not improve.
— Cognitive function did not improve.
— Mood and depressive symptoms improved slightly.
— Mild to moderate anemia improved as levels of hemoglobin (a component of red blood cells) rose.
— Bone density and estimated bone strength improved.
— Plaque in the coronary arteries increased — a potentially troubling finding.
— Men who received testosterone supplements were more likely to have increased levels of prostate-specific-antigen, or PSA, compared to men who received placebos. The PSA blood test is used to detect early prostate cancer. However, higher PSA levels can also indicate an enlarged prostate, or benign prostatic hypertrophy, or other non-cancer conditions.
Whether testosterone treatment poses an increased risk of heart attacks, strokes, prostate cancer or other conditions remains unclear.
“This is a very controversial area and a big problem is there are no sufficiently large or sufficiently long-term studies to answer this question,” says Dr. Eric Orwoll, a professor of medicine at Oregon Health & Science University. “On the basis of inadequate data, it appears there may be an increased risk of cardiovascular disease in older men who use testosterone,” he says. “And prostate cancer is a theoretical, but unresolved, concern.”
Health Conditions
Some medical conditions and treatments can lead to low testosterone and related symptoms, Orwoll notes, such as endocrine conditions like pituitary gland disease or cancer chemotherapy. “In those situations, it’s logical to ask a question about whether gonadal function is normal,” he says.
Diabetes, chronic obstructive pulmonary disease, or COPD, and advanced kidney disease are conditions in which sexual problems, unexplained weight loss, decreased mobility or weakness might be related to low testosterone in men, according to the Endocrine Society.
Regardless of symptoms, testosterone measurement should be considered for men with pituitary tumors, weight loss associated with the human immunodeficiency virus (HIV), or with certain fractures, the group recommends.
[See: What Only Your Partner Knows About Your Health.]
Testosterone Treatment Steps
If you’re concerned about symptoms that might be related to low testosterone levels, undergo a careful evaluation with your health provider, including the following:
— Talk openly about any symptoms bothering you.
— Undergo a physical exam. Your health care provider may check your genitals, body hair, breasts and other parts of the body for possible signs of testosterone deficiency. Other tests may be done to rule out alternative causes of any symptoms.
— Have blood testing for testosterone levels if indicated. Your doctor may order other, related blood tests as well. For accuracy and consistency, testosterone blood testing should be done in the morning. Repeat testing should be done at a later date rather than relying on a single blood sample.
— If your testosterone levels are clearly and consistently low, and you’re interested in treatment, discuss the risks, benefits and side effects with your doctor.
— Choose the right form of treatment for you. “Testosterone patches and gels are much more successful in establishing relatively stable, normal levels,” Orwoll says. “Injections are certainly efficacious but [a problem is] testosterone levels go quite high after an injection and peak at levels above normal, then fall relatively quickly — frequently to levels that are below normal — before the next injection.” However, intramuscular injections are less expensive, he notes, which sometimes drives insurance or patient decisions.
Once treatment begins, your doctor should periodically monitor your testosterone blood levels and treatment response. Other periodic blood tests might include PSA tests, red blood cell counts and cholesterol and liver function tests.
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Why Are Older Men Bailing Out on Testosterone Therapy? originally appeared on usnews.com
