“…once drugs are proven effective and approved for the specific population in which they are tested, they quickly end up getting prescribed to a wider body of patients than is likely needed or safe.” Health News Review
Testosterone and aging
If you’re a guy, the word hypogonadism is likely not a part of the words you say every day, or even every year. However, starting around age 45, you and your buddies might occasionally talk about low T, or low testosterone. The clinical term is hypogonadism (hypo = low, gonad = your testes, the two sex organs that produce male sex hormones as well as sperm).
Let’s face it. As men age, it is normal and natural for our bodies to produce less testosterone, the male hormone that regulates sex drive and fertility, bone and muscle mass, where fat is distributed in your body, the production of red blood cells, and the sperm needed to guarantee fertility. You know you’re getting older when your 17-year old son could probably win a wrestling match with you, you’re getting a paunch though you haven’t really changed your eating habits, and you’re less interested in having sex than you are in rolling over and drifting off to dreamland. When you do want sex, you may have performance problems. These may all be signs that your testosterone blood levels are decreasing. They do not, however, mean that you have a level low enough to qualify as hypogonadism.
Testosterone levels are determined by a simple blood test. Levels considered normal range widely from about 270 – 1070 ng/dL (average 679 ng/dL). Men tend to have peak levels around age 20 with very slow decline after peak. However, levels below 300 ng/dL become concerning when they interfere with quality of life, and such low testosterone, or low T, can occur for a variety of reasons beside getting older—though that is the most common cause.
The testosterone bandwagon
The effects of low T have long been known throughout history, but with the exception of experimental testosterone dosing created from animal testes, there were no consistent treatments. Beginning in 1935, development of a bioavailable form of synthetic testosterone began in earnest. Pills, injections and patches gradually came into existence, but there were various problems with each delivery system. A real turning point, however, occurred around 2000 with the creation of a testosterone gel that could be absorbed through the skin. Suddenly, testosterone replacement became a hot topic. It’s as if a Fountain of Youth bandwagon had rolled into town.
The rollercoaster ride begins
Testosterone replacement therapy (TRT) is a terrific resource for appropriate patients, but requires diagnosis and evaluation. The most prevalent cause of hypogonadism is aging. Guess what? A whole new marketplace presented itself to pharmaceutical companies with the national population “bulge” as the Baby Boomers began turning 45 in the early 1990s! The most effective tool in the drug manufacturers’ toolkits is direct-to-consumer advertising (DTCA). An article published in 2000 in The Journal of Clinical Endocrinology & Metabolism noted,
Succumbing to the pressure of perfectly sculpted, Adonis-like figures gazing down at them from news stands with captions provocatively entitled ‘Are You Man Enough?,’ men are now demanding their slice of the hormone pie.[i]
The roller coaster ride began as sales climbed precipitously. According to a 2018 article in MedPage Today, “From 2002 to 2013, total testosterone use by adult men increased six-fold, from 0.52% to 3.20%.” The global trend similarly reflected this surge: “One report from ABC News in 2012 said that the use of testosterone had doubled between 2006 and 2012 and was going to triple over the next five years.”[ii] At the same time, concern was growing in the medical/professional community that TRT was being oversold and overprescribed to counteract natural conditions of aging.
Then, in 2013 and 2014, a dramatic tipping point led to a steep fall-off. The roller coaster began a downward plunge due to the publication of two studies (2013, 2014) linking TRT to an increased risk of heart attack and stroke. Quickly, the FDA issued a safety bulletin, announcing an investigation into the correlation. On March 3, 2015, the agency released a caution against TRT use to counteract normal effects of aging; it also required drug companies to modify labeling (indicate appropriate use, warn about potential risk for heart attack and stroke). Thus, from 2013 to 2016, total use of TRT dropped by 48%, and the number of new users dropped by 62%. This occurred across all age groups, with those ages 65 or older showing the greatest decline at 69%).[iii]
Wise use of TRT
The Sperling Prostate Center supports TRT for appropriately qualified patients. If you are concerned, talk to your primary care doctor who may refer you to a specialist, e.g. endocrinologist. We also highly recommend having a baseline prostate scan done by 3T multiparametric MRI that serves as a reference point for potential prostate changes or suspicious areas. I have written about the safety of TRT for prostate cancer patients but with the caution that correct diagnosis, evaluation, and monitoring with 3T mpMRI and bloodwork are key safety factors.
The bottom line is: don’t jump on the bandwagon for its own sake. You and your doctor can make the wisest decision about TRT for you.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you have health concerns or questions of a personal medical nature.
[i] Hayes FJ. Testosterone – fountain of youth or drug of abuse? J Clin Endocr & Metab. 2000 Sep; 85(9):3020-23.