What are the symptoms of testosterone deficiency? Loss of energy, decreased strength, reduced exercise
capacity and erectile dysfunction are some. Testosterone deficiency may also contribute
to metabolic syndrome, loss of lean muscle mass, and osteoporosis. The ADAM questionnaire is a validated tool
that can help identify symptomatic men. Morley et al. Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism. 2000;49(9):1239-1242.
Testosterone deficiency may be diagnosed on the basis of
blood tests. Dr. Hsaio pointed out that saliva tests are not accurate. Typically total testosterone and free
testosterone levels are measured. Free
testosterone is the active version of the hormone. If levels are low and men are deemed symptomatic
treatment involves supplementation with testosterone, which is available in various
delivery systems including transdermal gels, patches and pellets (implanted
beneath the skin of the buttocks). Dr. Hsiao is of the opinion that injections
of testosterone are not as well tolerated as the other delivery methods as they
produce hormonal peaks and troughs that are associated with more adverse
effects including flushes.
Given the common nature of some of the described symptoms of testosterone deficiency it is not always clear who should be treated. One approach, for symptomatic men who have low or borderline testosterone levels, is a three month trial of treatment to see if symptoms improve.
Given the common nature of some of the described symptoms of testosterone deficiency it is not always clear who should be treated. One approach, for symptomatic men who have low or borderline testosterone levels, is a three month trial of treatment to see if symptoms improve.
What is the downside of testosterone replacement? One large
clinical trial reported in the New England Journal of Medicine in 2010
demonstrated increased cardiovascular events in men who were randomized to
treatment, and the trial was terminated early because of these adverse outcomes. However,
Dr. Hsiao is skeptical that these risks translate to all men, and he
noted that the population studied was primarily elderly, frail, and immobile.
Another concern with testosterone therapy is whether it has potential to promote prostate cancer growth in a man who may have subclinical prostate cancer or
prostate cancer that has not yet been detected, and also whether it can cause enlargement of benign prostate tissue and contribute to worsening of urinary
symptoms in men. Benign prostatic hypertrophy is another common condition that
impacts quality of life in men as they age by causing reduced ability to urinate. Dr. Xiao felt that evidence is lacking to suggest that either of these prostate conditions is affected much by
testosterone therapy and sited data supporting this viewpoint.
It’s good to know that testosterone therapy exists as an option to
help men with symptoms of andropause, which can adversely affect quality of life. However, those of us who have
doctored through the era of the Women’s Health Initiative, which studied the
effects of hormonal therapy for menopause, have to be somewhat cautious about
prescribing treatment for a condition that affects a huge segment of the
population. In the case of estrogen and progestin therapy in women, as
discussed in a recent blog, the pendulum
has swung for, then against, and now recently partially back in favor of a
cautionary approach to post-menopausal hormone replacement for symptom
management during the time immediately following menopause in women.
To date testosterone therapy has been less well studied, and it could
be years before the safety data for testosterone replacement in men is as good
as the data for hormone replacement in women, which has been the subject of
intense research in the previous decade.
