Are providers too cautious with prescribing testosterone therapy?
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Yes, strong evidence now supports using testosterone therapy more in practice.
Providers are too cautious with testosterone therapy. The myth is that increasing testosterone level will cause prostate cancer. If you start with a myth, you have to disprove that myth with a trial that is probably too big to ever conduct and that nobody will ever fund. Although repeated studies have shown no risks with testosterone therapy, those small studies are never looked at.
Testosterone therapy crosses a number of specialties, and we are a bit locked into our specialties. For example, the European Association of Urology recommends that anybody starting testosterone needs three rectal examinations in the first 12 months. The endocrinologists published guidelines that do not require a digital rectal exam at all. When you have guidelines, you need to make sure you have proper multidisciplinary panels.
If you read a summary of the T Trials, it tells you that there is high-level evidence that testosterone therapy improves cognitive function, improves muscular strength, improves insulin sensitivity, improves walking distance and sexual function. Yet in the final sentence, the experts say they advise caution until longer-term studies are available.
The European Male Aging Study showed that a 20% reduction in weight was required to achieve a significant reduction in free testosterone, and this is simply not achievable for the vast majority. Dietary interventions have repeatedly failed to produce meaningful long-term weight reduction, and U.S. obesity and diabetes rates increase year by year. In the T4DM trial, there was a 40% reduction in the testosterone therapy group for progression to diabetes. Diabetes is the biggest major health problem the U.S. faces. Testosterone therapy is a major step forward, but people just read the study and concluded they need longer-term information.
A bigger study is expected to come out later this year or early next. I’m still not sure it will satisfy everybody. But I think there are quite good studies out there now.
- For more information:
- Geoffrey Hackett, MD, FRCPI, is a professor of sexual medicine at Aston University Medical School and Spire Hospital Little Aston in the U.K.
No, testosterone is being prescribed for too many men who don’t need it.
There are certain cases where I think some people are being a little bit too cautious with testosterone. There are some doctors who may not be comfortable giving testosterone to a man who has coronary artery disease or a history of treated prostate cancer, whereas there are no good data showing that testosterone would harm men with this history.
But in many more cases, we have the opposite. Some clinics have been too liberal with dispensing testosterone for low libido or erectile dysfunction without doing an adequate assessment and evaluation. Many of these clinics are just out to make money by putting as many men on testosterone as possible. Testosterone should be prescribed to men who have androgen deficiency who are not able to make enough testosterone on their own.
Functional hypogonadism refers to low testosterone levels that are often borderline where there is no structural abnormality. A lot of times these causes are reversible. If you treat the underlying cause, that can reverse low testosterone levels without replacement therapy, for example, weight loss for obesity and increasing sleep in those with inadequate sleep.
We need more high-quality, randomized control trials that involve testosterone for a longer duration. A lot of patients are put on testosterone for years at a time, but we don’t have studies examining the effects of taking testosterone for years at a time.
- For more information:
- Michael S. Irwig, MD, is an associate professor of medicine at Harvard Medical School and director of transgender medicine at Beth Israel Deaconess Medical Center.
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