Testosterone replacement is becoming more mainstream as public awareness of the problem increases. This is a powerful male hormone responsible for many essential functions and secondary effects in the body. Unfortunately, aging causes our natural production of the hormone to decrease, resulting in side effects that can become bothersome. After the ages of 30-40, testosterone starts to drop off about 1% a year.
Symptoms can include low libido, erectile dysfunction, fatigue or tiredness, loss of mental focus, decreased muscle mass, increased body fat, depressed mood and (possibly) increased risk of cardiovascular disease, anemia and decreased bone mineral density.
There are many reasons a man can have low testosterone. Your doctor will perform a history and physical exam as well as blood work to determine if (and why) testosterone is lower than normal. If it is in fact low and symptoms are consistent with low testosterone, replacement may be indicated (depending on the severity of symptoms and the level of testosterone).
Testosterone replacement usually is given by transdermal (skin) gels, intramuscular injections or subcutaneous (under the skin) pellets/implants. There are pros and cons to each, and each has a select patient in mind.
The most important matter in regards to replacement are the potential side effects to testosterone replacement. These can include infertility, decreased testicle size, acne, swelling of feet/ankles, worsening prostate enlargement with possible bothersome urinary symptoms, worsening obstructive sleep apnea, worsening congestive heart failure, worsening liver disease, as well as polycythemia (increased red blood cell production), breast swelling/tenderness and emotional mood swings "roid rage." These are not guaranteed side effects, but they can occur. Patients and doctors have to be on constant vigilance if these side effects occur.
There is controversy surrounding testosterone replacement and its effects on prostate cancer and cardiovascular disease, as well. If a man already has prostate cancer (which may be undiagnosed), testosterone replacement may make the cancer more active. It does not likely cause prostate cancer, but your doctor may screen you for prostate cancer before replacing testosterone. Also, it is unclear if testosterone replacement increases a man's risk of cardiovascular disease. We know that having low testosterone possibly increases a man's risk of heart disease, and we also think replacing testosterone may increase it as well. This can be confusing. Definitive studies have not been performed, but hopefully will be done in future to clarify these questions.
Please read the American Urologic Association's position statement on testosterone therapy for more information.
As always, speak to your doctor about low testosterone as a possible cause of these bothersome symptoms.
AUA Position Statement on Testosterone Therapy
In a recent drug safety communication the FDA requires manufacturers of approved testosterone products to add labeling information about possible increased risk of heart attack and stroke. The American Urological Association (AUA) concludes that there is conflicting evidence about the impact of testosterone therapy on cardiovascular risks. Definitive studies have not been performed. The FDA drug safety communication cautions that benefits and risks of testosterone products for low testosterone due to aging are not clearly established. Hypogonadism is defined as biochemically low testosterone levels in the setting of a cluster of symptoms, which may include reduced sexual desire (libido) and activity, decreased spontaneous erections, decreased energy and depressed mood. Men with hypogonadism may also experience reduced muscle mass and strength and increased body fat. Hypogonadism may also contribute to reduced bone mineral density and anemia. Testosterone therapy is appropriate treatment for patients with clinically significant hypogonadism, including those with idiopathic clinical hypogonadism that may or may not be age-related, after full discussion of potential adverse effects. Patients should understand that treatment requires follow-up and medical monitoring. Testosterone therapy in the absence of hypogonadism is inappropriate.
Increased public awareness about hypogonadism has been stimulated by recent increases in availability and diversity of patient-acceptable forms of testosterone replacement options. Only FDA-approved medications should be used; over-the-counter preparations generally should be avoided based on lack of efficacy and safety data.
The management of hypogonadism should start with careful evaluation by a physician experienced in diagnosing and managing patients with hypogonadism. Many of the symptoms are non-specific and may be multifactorial in origin. Hence, symptoms may not be necessarily linked to hypogonadism alone. This fact needs to be considered in the overall evaluation. The diagnosis should be made only after taking detailed medical history, physical examination, and obtaining appropriate blood tests. Testosterone therapy should not be offered to men with normal testosterone levels. Testosterone therapy is never a treatment for infertility, and may cause infertility.
The AUA is also concerned about the risks associated with misuse of testosterone for non-medical indications, such as body building or performance enhancement.
The potential adverse effects of testosterone therapy should be discussed prior to treatment. These include acne, breast swelling or tenderness, increased red blood cell count, swelling of the feet or ankles, reduced testicular size and infertility. Current evidence does not provide any definitive answers regarding the risks of testosterone therapy on prostate cancer and cardiovascular disease, and patients should be so informed.
The optimal follow-up of men on testosterone therapy has not been defined, but should include measurement of testosterone level, PSA (for men of appropriate age) and hematocrit. Other patient-specific measures may be appropriate.
There is a critical need for more federal and industry funding of research to better understand indications, long term benefits and risks of current treatments of hypogonadism, as well as to develop new and improved treatment options.
AUA recognizes and encourages the increased educational awareness of the benefits and risks of testosterone therapy among both patients and healthcare providers. This statement has been endorsed by the American Society for Men's Health, the Sexual Medicine Society of North America and the Society for the Study of Male Reproduction.
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