Once a dominant narrative has been established, it can be exceedingly difficult to return to an objective stance where the evidence again becomes paramount.^[i]

According to Dr. Abraham Morgantaler, the author of the above quote, for men with low testosterone blood levels (testosterone deficiency or TD), testosterone therapy is “simply good medicine.”

Morgentaler is well positioned to make this statement. He has been working with testosterone (T) for nearly 40 years as a researcher and clinician. He has seen a seesaw of enthusiasm for testosterone therapy (TTh) over that period. In the 1940s, there was a bandwagon view of TTh as some kind of cure-all for what ails men in the throes of ED, lackadaisical mood, puny muscles and more. Then, when what turned out to be flawed studies attaching risk of prostate cancer (PCa) and cardiovascular disease (CVD) to TTh use, the seesaw tilted in the opposite direction. TTh fell into disfavor and disuse. Why?

In Morgentaler’s analysis of the situation, it was a backlash to widespread “advertising by for-profit clinics and especially by supplement companies making over-the-top claims…” This led to a “skeptical public, including physicians” who jumped on the negative narrative that TTh could harm men. He also points to insurers’ rigid cost-saving guidelines of threshold T levels above which they won’t reimburse.

Let’s look at the facts

In Morgentaler’s concise analysis of the contemporary history of TTh, he counters earlier evidence that underlies the two main TTh fears: 1) its relationship with PCa, and 2) its impact on cardiovascular health. After describing the erroneous research results, he offers better science:

1. Previous beliefs that higher T levels raised PCa risk were partly fueled by the observation that depriving PCa patients of this male hormone (androgen deprivation) halts the disease some period of time. Newer studies support what is called the saturation model which posits a limit (leveling off) of the effects of androgen on prostate tissue. This allows TTh to be offered to select PCa patients with TD. A study comparing PCa patients on active surveillance who were also receiving TTh vs. similar patients with TD who did not receive TTh found no difference in progression rates. Furthermore, Morgentaler’s own research found that men with normal-to-high T levels had no increased risk of developing PCa, nor did TD men on TTh who had no personal history of PCa. Most strikingly, recent studies have actually found a correlation between low T levels and worse PCa disease and prognosis.
2. Testosterone and CVD – Here again, higher quality research dispels the myth that TTh puts men at risk of CVD. In fact, TTh has been demonstrated to reduce the incidence and mortality of CVD. It has been “shown to improve known CV risk factors, such as reducing fat mass, resolving the metabolic syndrome [obesity and diabetes], and improving glycemic control.”

Issues surrounding patient selection to TTh

When it comes to defining what constitutes TD, here too the pendulum has arced from one end to another. In reviewing the past 40 years, Morgentaler points out that simply trying to establish TD based on a blood draw has posed challenges. In the beginning, diagnosing low T levels was based on clinical factors reported by the patient. Then, in the 1970s, lab analysis made it possible to measure blood levels, so the pendulum swung in favor of blood tests. However, this led to differing “low T” thresholds on the part of professional groups and experts.

According to Morgentaler, “This confusing situation is worsened by the recommendation by the Endocrine Society in 2010 to follow reference ranges provided by the laboratory performing the testosterone testing, because there is so much variation in reference ranges across laboratories…” with the result that there is no single number that reliably indicates who should or should not receive TTh based on a blood test alone. In Morgentaler’s own practice, they improve the diagnostic blood level reliability by measuring free testosterone in addition to total testosterone.

Even so, Morgentaler strongly recommends bringing the pendulum back to the patient’s overall symptoms. He decries the pressures created by Medicare’s reimbursement restrictions based on laboratory T results as lacking a scientific basis, not to mention interfering with good medical practice. He argues, “The diagnosis of TD requires clinical judgment, and attempts to replace this with irrational adherence to arbitrarily selected values prevent healthcare providers from offering important treatments to appropriately selected patients.”

The bottom line

It’s time to dispel the negative narratives about testosterone therapy. TTh has potential for future roles in PCa management, weight loss management, and prevention of CVD. To get there, more large-scale, high-level studies are needed. For now, based on 40 years’ observation, we know that when properly prescribed, TTh is safe for all men plus carefully chosen PCa patients. Just as important, it is broadly beneficial for men whose quality of life and physical wellness are compromised by TD. Thanks to Dr. Abraham Morgentaler for great myth-busting in a single informative article.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Morgentaler, A. Controversies and Advances With Testosterone Therapy: A 40-Year Perspective. Urology. 2016 Mar;89:27-32.