DOCTOR'S VIEW ARCHIVE
Medical Authors and Editors: Barbara K. Hecht, Ph.D. and Frederick Hecht, M.D.
Jan. 29, 2004 -- Testosterone replacement therapy has been controversial in elderly men -- say, men over 65. Despite this controversy, testosterone supplementation has increased "substantially." There has been a rise of more than 500% in the prescription sales of testosterone products in the United States since 1993.
It has been full speed ahead, even if we don't know where we are going.
To try to make some scientific sense of the situation, The New England Journal of Medicine today has a critical review on the subject. The article considers data from 72 studies pertaining to the risks of testosterone replacement therapy.
The compendious (comprehensive but brief) review was prepared by Drs. Ernani Luis Rhoden and Abraham Morgenthaler from the Division of Urology at Beth Israel Deaconess Medical Center and Harvard Medical School. Neither author declared any ties to makers of testosterone products or other conflicts of interest
Many studies have documented that the blood levels of testosterone in men decrease as they age. This decrease in testosterone in men occurs moderately and gradually over a period of several decades.
One essential but still unanswered question is whether this decrease in testosterone with age is physiologic, perhaps conveying a benefit, or pathologic (abnormal), causing harm to men.
Another unanswered question is whether testosterone treatment is beneficial to older men. The highly respected Institute of Medicine recently concluded that there is insufficient evidence to say that testosterone treatment benefits elderly men.
Another essential but still unanswered question is whether reversing this decline in testosterone will exacerbate the testosterone-dependent diseases to which elderly men are prone such as prostate cancer, benign prostatic hyperplasia (enlargement of the prostate), erythrocytosis (too many red blood cells) and, perhaps, sleep apnea.
No data, unfortunately, are available with which to answer these questions.
In an editorial in today's New England Journal, Dr. Peter Snyder from the University of Pennsylvania, proposes "what to do until the evidence comes." He provides four principles to follow.
The first principle is that the criteria for the diagnosis of testosterone deficiency should be more stringent in the absence than in the presence of a disease that is known to cause hypogonadism. And the criteria for the diagnosis of testosterone deficiency should be more stringent in an older man than in a younger man.
The second principle is that the replacement of testosterone should be considered only if testosterone deficiency can be demonstrated on the basis of these stringent criteria.
The third principle is that older men who are treated with testosterone should be monitored to ensure that the goal of replacing testosterone is achieved. The response of the blood testosterone concentration to treatment should be carefully monitored.
And the fourth principle is that older men who are treated with testosterone should be monitored for possible worsening of diseases, including prostate cancer and benign prostatic hyperplasia, that may be testosterone-dependent.
Comment: Since hormone therapy for older women has turned out to have more risks than benefits, we believe that hormone therapy for older men should be approached with caution. A rush now to testosterone may be regretted later.
Related MedicineNet.com Links
- Testosterone replacement therapy
- Focus Topics on Men's Health
1. Rhoden EL, Morgenthaler A. Risks of testosterone-replacement therapy and recommendations for monitoring. New Engl J Med 2004; 350: 482-92.
2. Snyder PJ. Hypogonadism in elderly men -- what to do until the evidence comes. New Engl J Med 2004; 350: 440-442.