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Berkeley Wellness Alerts
January 10, 2012 | Comments: 13
The Lowdown on Low Testosterone
Men generally experience a slow but steady decline in testosterone over the decades, mostly after age 50, sometimes likened to menopause in women. Is low testosterone a cause for concern?
If a man’s testosterone level drops substantially, it’s often called andropause or late-onset hypogonadism, though there’s much controversy about how to define this and thus how common it is. As with menopause, pharmaceutical companies and “anti-aging” clinics are eager to medicalize andropause and market remedies for it, making it sound as if many, perhaps most, older men should be taking supplemental testosterone to regain youthful vigor and reverse any andropause-related symptoms. Here’s what to know before you jump on the testosterone bandwagon.
Low testosterone: not so clear-cut
Testosterone is the male equivalent of estrogen, a hormone that controls many aspects of sexuality as well as secondary sexual characteristics, such as facial hair, musculature and voice quality. No one knows exactly what role declining levels of testosterone play in aging. Keep in mind:
• Though researchers have come up with age-related ranges of “normal” testosterone, blood levels vary greatly from man to man, and even during the course of the day in the same man. Expert groups have different cutoff points for low testosterone, and no one knows what optimal levels are.
• Estimates of how many older men have low testosterone levels for their age vary widely (from 5 to 35 percent) depending on how these are defined and which forms of testosterone in the blood are measured.
• Low testosterone, however it’s defined, is not a problem unless it is accompanied by undesirable symptoms such as low sexual desire and erectile dysfunction. Some guidelines require the presence of such symptoms for a diagnosis of age-related hypogonadism (andropause) to be made.
• In some men, low testosterone leads to decreased sexual drive, erectile dysfunction, loss of muscle and bone, fatigue and other problems. Thus, supplemental testosterone is sometimes prescribed for older men with these problems, though the evidence of its effectiveness is mixed. These problems can have many other causes, of course. As shown in a New England Journal of Medicine study in 2010, most men who had sexual symptoms had “normal” testosterone levels, while most men with low testosterone had few, if any, related problems.
• Low testosterone is also often associated with diabetes, bone loss, obesity and high blood pressure. But it’s not certain whether low testosterone is a cause or effect, or whether supplemental testosterone can help these conditions.
• Testosterone therapy has been linked to an increased risk of prostate cancer and heart disease, along with liver damage, sleep apnea, breast growth and prostate enlargement. As with the proposed benefits, however, the evidence concerning most of these risks is inadequate or inconsistent.
Who needs testosterone “replacement”?
Some genetic disorders and other conditions, as well as certain medications, may result in a dramatic drop in testosterone in both young and older men. Such men may benefit from prescription testosterone therapy, but only on expert medical advice. This is a serious decision, since the long-term risks are unknown.
Words to wise men:
Though testosterone is essential for making males masculine, lower levels as you age do not mean you are less of a man. Older men in good health can remain fit and stay sexually active. Hormone levels are only one part of the equation. Don’t assume you need testosterone therapy if you feel your libido is dropping off. But if you’re concerned about that or have other symptoms that may be related to reduced testosterone, talk to your doctor.
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Please don't try to scare men away from an effective treatment that doesn't require using another drug. Studies clearly demonstrate that men's testosterone levels have been dropping decade after decade and optimization/supplementation may go a long way in correcting many of the medical issues that plague men. Low testosterone levels is not about sex, it is about health and this is backed up by numerous medical studies.
Posted by: ChrisNagy | January 14, 2012 8:24 AM
Chris...if you are not talking about another drug, and only some kind of supplement, why not name this substance, or is it an exercise? that could help optimize the health of aging men? My husband has lost two inches of height and he's only 60 years old.
Posted by: FishPillHappy | January 14, 2012 12:00 PM
I am speaking about the beneficial effects of a properly optimized testosterone level. I don't consider testosterone a drug as it is a naturally occurring substance in the human body. I guess it is a matter of semantics but there is a difference between a drug and a hormone (unless of course it is a synthetic hormone, never having occurred in nature, then it is a drug and thus used as one). Of course exercise is important and will help raise testosterone levels but sometimes appropriate supplementation is necessary to improve a low level. A low level in an older man is called aging, a low level in a young man receives treatment - the choice is a philosophical one. Medicine is so busy helping to keep people from dying that we rarely help them with living. Optimal living requires a whole range of lifestyle changes/alterations, one of which is addressing hormonal deficiencies.
Posted by: ChrisNagy | January 14, 2012 12:20 PM
Mr. Nagy, Here is a fuller article about testosterone therapy that ran in the Wellness Letter: http://www.wellnessletter.com/html/wl/2011/wlFeatured0511.html Testosterone is indeed a drug when administered as a medical intervention. Women and their doctors said the same thing about estrogen therapy (it can't hurt, it's natural, look at all the benefits, we're only replenishing natural levels), and then clinical trials confirmed all sorts of dangers. Women by the millions stopped taking estrogen as a result. You may feel comfortable being a guinea pig, but until good clinical trials show benefits and few/no risks, we can't recommend testosterone therapy for most older men.
--The Editors
Posted by: Michael Goldman | January 14, 2012 1:01 PM
As stated, this is a matter of semantics. I agree with your assessment that all of the answers are not in yet, as they are not (nor likely ever will be). Reference Harvard's, Dr. Abraham Morgantaler's work as the most up to date work on testosterone. And yes, testosterone is a drug but it is also a hormone and always was a hormone before it was considered a "drug." I disagree with your comparison between women's and men's hormone replacement. As you know, women's hormone replacement has traditionally consisted of using Premarin (extracted from pregnant mare urine) and medroxyprogesterone (a synthetic form of progesterone never before encountered by the human body). This combination increases the risk of cancer because they are not hormones (though they mimic hormones) but drugs. Since when is a woman a horse and why does it make sense to give her horse estrogen? A physiology book clearly explains this. Studies (involving 80,000 and 54,000 women) have verified a decreased risk of breast cancer using biologically identical hormones over synthetic hormones. I would be happy to provide references. Please do not muddy the waters or confuse without considering all of the literature available. Testosterone replacement is done with biologically identical testosterone, not a synthetic drug. There are good studies that show great benefits and acceptable risk when properly implemented. We use drugs to treat all of the individual problems listed in the article, why not replenish what the body is missing/lacking rather than add something to treat each condition separately (3 or 4 different drugs)? Isn't all of what we do in medicine making us guinea pigs in one way or another? Thank you for your consideration.
Posted by: ChrisNagy | January 14, 2012 3:38 PM
Yes, we would be interested in seeing the studies on estrogen therapy that you mention, assuming they have been published. "A physiology book clearly explains this. Studies (involving 80,000 and 54,000 women) have verified a decreased risk of breast cancer using biologically identical hormones over synthetic hormones. I would be happy to provide references." This is Suzanne Somers territory, and we've never seen good evidence for such claims--let alone studies with 80,000 women.
--The Editors
Posted by: Michael Goldman | January 14, 2012 7:49 PM
Yes, we would be interested in seeing the studies on estrogen therapy that you mention, assuming they have been published. "A physiology book clearly explains this. Studies (involving 80,000 and 54,000 women) have verified a decreased risk of breast cancer using biologically identical hormones over synthetic hormones. I would be happy to provide references." This is Suzanne Somers territory, and we've never seen good evidence for such claims--let alone studies with 80,000 women.
--The Editors
Posted by: Michael Goldman | January 14, 2012 7:49 PM
Here you are. I will be interested in your thoughts and thank you for following through and calling me on it. We're all here to learn.
http://www.ncbi.nlm.nih.gov/pubmed/15551359
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2211383/
http://www.ncbi.nlm.nih.gov/pubmed/19179815
http://www.ncbi.nlm.nih.gov/pubmed/17651686
http://www.ncbi.nlm.nih.gov/pubmed/18775609
Posted by: ChrisNagy | January 14, 2012 9:04 PM
Missed one.
http://www.ncbi.nlm.nih.gov/pubmed/17012103
Posted by: ChrisNagy | January 14, 2012 9:22 PM
It's unclear how those papers prove that bioidentical hormones (especially those being marketed here) are safe, or even safer, but our editorial board will review them. The latest review article on the subject, from the Mayo Clinic in 2011, concluded "No evidence currently suggests that custom CBHT formulations offer clinically relevant benefit over the FDA-approved products available to treat the symptoms of menopause." Earlier it stated "Advocates for CBHT [compounded bioidentical hormone therapy] have claimed that estriol, given its decreased estrogenic activity, is not only safer but also associated with a decreased breast cancer risk. Some sources found on Internet sites go so far as to claim that it protects against cancer, yet no controlled trials substantiate this claim. Moreover, concerns have been raised about the continued use of estriol in high doses and its potential risk for stimulating breast parenchyma."
http://www.ncbi.nlm.nih.gov/pubmed/21531972 Mayo Clin Proc. 2011 Jul;86(7):673-80
Hormones are risky business. We advise our readers, male and female, to beware of the risks.
--The Editors
Posted by: Michael Goldman | January 14, 2012 10:05 PM
You are correct, hormones are risky business. That is why, I feel it is preferable, if needed, to restore hormone balance with hormones that are biologically identical to the hormones that have been lost. If given a choice, any man or woman would choose a molecularly identical hormone (FDA approved or compounded) rather than an option that is close to but not identical to what was recently lost or diminished. Intuitively, do we need a study to state that replacing hormones with what the body recognizes as a normal hormone is better than replacing what is missing with something the body has never seen or encountered before? Science is not about belief but about facts, thus the physiology book reference. There is no science supporting the lowest dose for the shortest time possible either but that is what is now recommended. ACOG has retired numerous (17) position statements involving this topic - clearly a topic that continues to evolve. Follow physiologic principles and you will experience a better outcome. Thank you for this discussion.
http://journals.lww.com/journalppo/Fulltext/2009/04000/Hormone_Replacement_Therapy__Real_Concerns_and.1.aspx
Posted by: ChrisNagy | January 14, 2012 10:25 PM
Some final thoughts from John Swartzberg, M.D., the Chair of our Editorial Board:
There is no way to resolve this. The state of our current understanding is, as we said in the Wellness Letter, we do not know if declining testosterone levels (free or bound) in aging men represents a problem to be treated or a compensatory mechanism to maintain health (or both!).
A generation from now, men in the 5th decades and beyond may be treated with testosterone. Or, we may find that low testosterone levels are a surrogate for another problem that requires intervention, or that declining testosterone levels represent the healthy state (and, we should augment that with anti-testosterone medications!). We just don't know --- that's the most honest answer. --The Editors
Posted by: aklausner | January 17, 2012 3:17 PM
" Women and their doctors said the same thing about estrogen therapy (it can't hurt, it's natural, look at all the benefits, we're only replenishing natural levels), and then clinical trials confirmed all sorts of dangers. Women by the millions stopped taking estrogen as a result. You may feel comfortable being a guinea pig, but...."
"Hormones are risky business. We advise our readers, male and female, to beware of the risks."
To the Editors:
I'm FURIOUS when I read this sort of thing. Those studies were based on synthetic hormones and their is NOTHING to support the "DANGERS" of bioidentical hormones [whether compounded or prescribed on the market], particularly when given in patch form where it bypasses the liver. I experienced two years of pure hell, including night terrors because of hormone issues and thanks to a medical profession that bases recommendations on a study that is inappropriately generalized, it took me two years of my own research, a lot of $, and a hell of a fight to advocate for myself before I REGAINED my health ON HORMONES. If I opted to "go natural", I don't believe I would be here today.
To the women [and men, too] out there, I would encourage you to check out Dr. Elizabeth Vliet's website who cites numerous studies, as well as her own observations in the women she treats. The Europeans studies are far more up to date on this!
Posted by: faith | January 23, 2012 8:09 AM