The big business of treating “Low T” gets front cover status in this week’s Time Magazine. Testosterone therapy dangles the suggestive notion that treating low T can decrease belly flab, decrease fatigue and improve performance in the bedroom. Today, testosterone replacement (or boosting) tips 2 billion dollars a year, up 500% in 10 years with sales of testosterone hormone replacement therapy just 400 M a year in 2004.
As I read the story I couldn’t help but sense we have been here before.
WHAT CAN STUDIES OF HORMONE REPLACEMENT STUDIES IN WOMEN TELL MEN?
In the Time magazine article, David Von Drehle reminds us that ” testosterone therapy shares a lot of the intellectual scaffolding that once supported hormone replacement therapy (HRT) for women.” The Women’s Health Initiative (WHI) was a major 15-year research program to address the most common causes of death, disability and poor quality of life in postmenopausal women — cardiovascular disease, cancer, and osteoporosis. As HRT gained traction, it seemed like every one of my female clients between the age of 40 and 70 years of age was taking “prem-pro” a combination of estrogen and progesterone.
Most women dutifully followed doctor’s orders, all in the name of reducing risk of heart disease, but by 2004 the study cohort of women taking estrogen were found to have increased risk of stroke. After 5 years the estrogen-plus-progestin trial stopped when researchers noted an increased risk of breast cancer. Ultimately the increased risk of breast cancer, coronary heart disease, stroke, and blood clots outweighed the proported benefits on hip fracture and colorectal cancer. Today the “FDA recommends that estrogens and progestins should be used at the lowest doses for the shortest duration needed to achieve treatment goals.”
TREATING LOW T
David Von Drehle effectively points to a range of issues swirling around surging sales of testosterone. The seduction of “power, performance, and passion” is clear, but much is not. I was astonished to read that there is little agreement to what level of testosterone in the blood is considered “low” or what is the proper way to measure testosterone. As with most complex issues, many question whether low T is actually the cause of andropause symptoms–or a symptom itself caused by other factors. For those of us working in the trenches this conumdrum is common. Too much research simply establishes correlation, unable to determine cause or effect.
If low T is a symptom, what could be the cause? In too many cases poor diet, lack of exercise, excessive stress, inadequate sleep and increasing body fat (especially the central body fat associated with increased risk of inflammation and most life-style diseases) set triggers the metabolic cascade that causes low T. Likewise improving diet, increasing exercise and managing life more effectively can reverse the condition. One small study conducted at Columbia University demonstrates exactly how that happens.
BOTH TESTOSTERONE REPLACEMENT AND PLACEBO EFFECTIVE
In a randomized controlled trial of 30 subjects some men were given shots of testosterone and others were given shots of sesame seed oil. All the subjects suffered from depression and erectile function disorder. At the end of the study, many participants reported improvements in mood and function, but there was no significant difference found between the groups. In the Times article, Mr. Drehle deftly outlines how the placebo effect takes place.
Testosterone therapy provides hope, and once a subject feels hopeful he may start eating better, then he may start exercising more. As he takes better care of himself, maybe he’s more able to handle stress at the office or sets different boundaries so he manages everything better. As he feels better and looks better, his libido returns and so does greater confidence in the bedroom. Many would give all the credit to the testosterone, but the Columbia study suggests that a better diet, more exercise and better stress management allow all sorts of systems to operate at a higher level.
IS THERE A DOWNSIDE TO TREATING LOW T?
So maybe taking testosterone helps even if it just a placebo effect. Is there a downside to treating “low T?. The researchers at Columbia University state, “Testosterone is not a silver bullet.” In fact, in all the hype it is easy to lose sight of the fact that treating low T doesn’t happen in a vacuum. The human body is complex and testosterone is just one of a variety of factors that influence mood, mindset, energy and weight.
Both the chemistry and the behavioral issues remain complex. What works for one person may not work for another. In addition, failing to address diet, exercise and stress leaves one open for all the other reasons one may be suffering fatigue and having issues in the bedroom: diabetes, cardiovascular disease, high blood pressure…and the medications used to treat these conditions. Slapping on a testosterone patch or a squirt of andro-gel doesn’t begin to address that complexity.
And the risks are murky since there are no testosterone drugs approved as a treatment for low T. Despite the void, the number of prescriptions for testosterone in the US jumped tenfold from 2000 to 2011 with physicians using (some same abusing) “off label” privileges. Online pharmacies in Canada filled millions more, and some men bypass the docs altogether and purchase T-boosting supplements over the counter.
Recently the FDA acknowledged a few studies showing increased risk of heart attack and stroke for some men taking testosterone. In response and with so much unknown, the FDA will convene a meeting of experts in September to sort it all out. In the meantime, those of us working in the trenches are left to sort things out on our own.
IS THERE A LINK BETWEEN STATIN THERAPY AND LOW T?
Just yesterday I was talking to a retired gentleman who complains of fatigue and would like to lose some belly fat. He showed me his recent blood work, including doctor’s records of progressively lower testosterone levels over the past 10 years. The tests also showed very low cholesterol levels due to statin therapy. Hmmm. The body synthesizes testosterone from cholesterol. Could there be a link? A meta analysis published in 2013 says yes, and “raises the question as to whether testosterone modulation plays a role in statins’ effects on health, particularly among men where testosterone is an important hormone.” I am intrigued with the upswing in the use of statins tracking with a parallel increase in prescriptions for testosterone.
My client knows his next step, and it’s not to his cardiologist who insists he will be taking the statin “for the rest of your life.” After thoughtful discussion, he decided he will first talk to his regular doctor, reminding him of links between cholesterol, statin therapy, and low T and go from there.
Today it is estimated that one out of every four people over 45 years of age takes a statin drug. With over 140 billion dollars lifestime sales of Lipitor alone, so many people take statins that toxicologists can measure it in the water. Just last week the Daily Health Post reported that over 1000 lawsuits have been filed against Pfizer, the manufacturer of Lipitor. I wonder if any one of those lawsuits says anything about low T.