We Age
Because Our
Hormones Decline

Risks of Testosterone Replacement Therapy in Men

As mentioned several times on this site, there is extensive evidence that testosterone replacement for treating ‘hypogonadism’ is both warranted and FDA approved. At some period during his life many a man will begin to experience a decline in free- and total testosterone levels. Whether that happens in his mid-thirties or forties, or not until his fifties, it will eventually drop to a lower level than when he was twenty. He is fortunate, if he has a doctor who checks and tracks testosterone levels. If his levels drop below 300 ng/dl (nanograms per deciliter), there is no controversy: he should have treatment. The controversy arises when considering, for instance, the 50 year old, healthy male with a total testosterone level of 500 ng/dl and free testosterone levels at 90 ng/dl whose level in his early twenties was 800. Does he have to wait until he drops to some “magic” level of 300 ng/dl total testosterone to begin TRT? Isn’t it enough that his level has dropped more than 30 percent; he has had trouble making progress at the gym; and he finds it tougher to lose weight around his waist?

Two questions arise when pondering this controversy. 1) Are there benefits when a testosterone level is raised from 500 to 800 ng/dl? 2) If so, are there any significant short and long term risks to therapy that achieves and maintain this level of testosterone? The first is the “Why” question (“Where’s the beef?”); the second is a question of healthy scepticism, because as we all know, there’s no “free lunch.”

Many studies on healthy young men gave doses of testosterone that elevated their levels into the high adolescent (1000 to 2000 ng/dl) range. In each of these studies, lean muscle mass increased and fat mass decreased. Comparable studies with lower doses were done on moderately obese men and these delivered both lean mass increases and even more fat decreases. Furthermore, the pre-diabetic state called insulin resistance improved, triglyceride levels decreased, and energy increased. The bonus outcomes are that, not one of these studies saw the increased aggressive behavior that many people expect to happen from high doses of testosterone.
 
Voluminous studies showing similar outcomes in older men (over 65) with mildly low testosterone levels have been published. The National Institute on Aging (NIA) has published the results of research into TRT’s effect on body composition (lean muscle and fat ratios). In their studies of 108 men, the findings showed a 6 lb. fat loss and 5 lb. lean muscle gain when testosterone levels were elevated from an average of 370 ng/dl to 640 ng/dl for 36 months. The same 108 men showed increased bone density if it had been low when they started treatment. As the evidence accumulates, all of it shows that when you raise the testosterone level—no matter what the starting level—you reap the benefits in body composition. Because of our experience with patients, we think the dose of testosterone used in the NIA study was too low. We believe that higher doses would have delivered even more impressive results with no significantly increased adverse effects.
 
Short Term Risks
 
Now, what about the question of a “free lunch”? Happily, what we call “side effects” or short term risks, are few. If you had a tendency to have acne as a teenager, it could reoccur when your testosterone levels are raised back to your adolescent levels. That we can effectively treat with topical or oral medications. If you tend to lose scalp hair, that can be intensified as well. However, this too can be effectively treated with a medication called finasteride or Propecia that inhibits the conversion of testosterone to dihydrotestosterone.

Prostate Health
 
The chief concerns men face with regard to long term TRT is whether it increases their risk of prostate cancer, enlarged prostate (BPH), and cardiovascular disease. We keep our patients within their physiologic (natural) replacement levels, at which there have been no evidence of symptoms or any increased risk of prostate cancer or enlargement. In truth, the longest forthcoming study is that three year NIA study we mentioned, that did not show any prostate problems.  The overwhelming majority of clinical studies have been case-controlled, epidemiological, and retrospective. They followed men collecting past data for many years and show no increased risk of prostate problems in men whose testosterone levels are higher than average. The thought that TRT increases the risk of prostate cancer is due to the well-documented fact that prostate cancers shrink when deprived of testosterone. Please note, however, that fact not prove that TRT causes or initiates prostate cancer. If you do have an undetected (occult) cancer, testosterone may cause it to grow, but every single one of our patients are screened with not only a total PSA, but also the newer, more specific free PSA before starting TRT. In addition, we do on-going to monitoring twice yearly.

Cardiovascular Disease
 
Worries about how testosterone and heart disease are linked arise from the fact of standard differences between men and women. Because men have higher incidences of heart disease and higher testosterone levels than women, some people make the mental leap that this means higher testosterone levels cause the greater incidence of heart disease. This is just another example of false reasoning that troubles the field of hormone replacement therapy. Understand this please: just because two conditions are found in the same group of people, it does not necessarily mean that one of them causes the other. In fact, when it comes to testosterone levels and heart disease, we have the results of many studies showing exactly the opposite. This issue has been studied extensively. It has been proven that there is a greater incidence of heart disease in men with low testosterone levels than those with high levels. Even more vivid are the effects of how testosterone given intravenously during attacks of angina dramatically improves symptoms. Other studies researching the effect of TRT on cholesterol levels universally found decreases in total cholesterol, LDL, and triglycerides, with no change or just slight decreases in HDL. Besides, as we mentioned, restoring youthful testosterone levels often reverses the metabolic syndrome increasing the risk of cardiovascular disease. So, it’s better to hear the truth than listen to prevailing inaccuracies.
 
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