Mainstream urologists have long known that testosterone replacement therapy (TRT) is vastly—and dangerously—overprescribed. According to an evidence-based clinical practice guideline recently published in Annals of Internal Medicine, physicians should prescribe testosterone for men with age-related low testosterone only to treat sexual dysfunction. The evidence does not support prescribing TRT for men with concerns about low energy, decreased vitality, cognitive impairment, and increased belly fat (the “grumpy old man syndrome”).
It is a fact that all men experience a gradual decline in serum testosterone levels starting in their midthirties, at a rate of about 1.5 percent per year. This phenomenon is known as age-related low testosterone. Approximately 20 percent of men over sixty years old, 30 percent of men over seventy, and 50 percent of men over eighty have low testosterone, but the rate of erectile dysfunction in these age groups is far lower. Confusion often arises because some symptoms associated with age-related low testosterone can also be caused by other factors such as medication or chronic illness (including hypertension, cardiovascular disease, coronary artery disease, high cholesterol, or dementia).
If TRT is deemed an appropriate treatment by a qualified doctor for age-related low testosterone associated with sexual dysfunction, it cannot be taken orally because it poisons the liver. TRT can be absorbed through the skin with a patch or cream (which are expensive) or can be self-administered by an injection every three weeks (which is inexpensive). However, any patient receiving TRT must have his blood serum testosterone levels measured every three to six months because an excessively high level of circulating testosterone thickens the blood and puts the patient at risk for stroke or heart attack.
Studies reveal that testosterone was frequently overused in recent years, which is believed to result from the plethora of synthetic TRTs now available on the market as well as the constant and pervasive advertisements for such substances. The popularity of FDA-approved medications like Axiron, Fortesta, Testim, Bio-T-Gel, and AndroGel has been further boosted by technology that allows these drugs to be absorbed through the skin as patches, gels, or creams.
But even when used by men with hypogonadism (legitimately low testosterone), these medications carry certain dangers. All of these drugs can cause decreased sperm count, thickening of the blood, and acceleration of a previously undiagnosed prostate cancer.
Compounding the problem (and trying to ride on the coattails of legitimate TRTs) are an endless number of non-FDA-approved supplements that are heavily promoted through exaggerated or outright false claims. These snake oils are marketed with promises to melt body fat; improve motivation and zest for life; recharge energy; increase strength, stamina, and athletic performance; enhance sexual function; and bring back romance. With names like Troxyphen, HexaTest, High T, Manimal, and Andro400, these supplements are guaranteed to benefit the seller far more than the buyer. These products are not FDA-approved, nor are they generally tested to see how well they work. Advertisers can make any claim without needing to verify it.
“It’s just a bunch of nonsense,” said Dr. Ellis Levin, chief of endocrinology, diabetes, and metabolism at the University of California, Irvine, School of Medicine. “People can claim whatever they want, and nobody will hold them to the truth.”
However, hypogonadism is a real medical problem, and patients with abnormally low testosterone levels will benefit from TRT. To establish this diagnosis, a blood test measuring testosterone levels must be done by a responsible physician or a lab. (Normal levels of testosterone usually exceed 265 nanograms per deciliter of blood.) The test must be performed twice—once in the morning, when circulating testosterone levels are at their highest, and once after fasting. If both levels are low, the patient is an excellent candidate for TRT. Once treatment has begun, testosterone levels must be monitored to ensure that they remain within the normal range so as to be therapeutic without being harmful.
Another key issue when dealing with male sexual dysfunction or male sexuality in general is the placebo effect. Over the years, much of male sexuality has been defined as “99 percent between the ears and 1 percent between the legs.” In many scientific studies, about 40 percent of subjects who received a placebo instead of a TRT drug claimed to experience benefits similar to those reported by patients who received the medication. The unscrupulous marketers of non-FDA-approved products and supplements, who often make bold and false claims that love, sex, size, desire, and performance will be enhanced, rely on this placebo effect. Male sexuality—being so intertwined with imagination, mental gymnastics, the power of suggestion, and the illusion of sex appeal—becomes the perfect target for the thousands of lucrative male “enhancement” products created by such businesses. TRT is a legitimate and necessary treatment for patients with hypogonadism or age-related low testosterone, but these men represent a minority among the number of guys who spend their hard-earned dollars on worthless placebos.
The takeaway message is that if you have genuine symptoms of age-related low testosterone associated with sexual dysfunction, then you would be wise to seek care from a competent urologist, have your testosterone levels tested, and—if you are deficient—use an FDA-approved product prescribed by your doctor.