Testosterone levels in men undergo a significant decline starting in some cases in the 30’s. This decline has led to the label of Androgen Deficiency (AD). The decline in testosterone is accompanied by a rise in the hormone estradiol. As men age, they increasingly convert testosterone to estrogen in a process called aromatization. The net effect is a reduction in the overall amount of testosterone relative to estrogen which leads to a variety of unwanted symptoms. These include:
- Fatigue/ low energy
- Weight gain
- Poor concentration
- Reduced sex drive
- Loss of muscle mass
- Erectile dysfunction
More serious metabolic disturbances associated with these declining testosterone levels can occur including increased fat mass, reduced insulin sensitivity, increased blood sugar levels and increased cholesterol and blood lipid abnormalities.
It is still not completely understood how declining testosterone levels contribute to a rising incidence of diabetes, heart disease, stroke and metabolic syndrome. It is also not yet known what the role of declining testosterone has in association with these conditions or if there is just a simple association. It is possible that low testosterone and these diseases are linked without a direct cause and effect relationship and that other factors may be involved.
Part of the difficulty lies in the fact that the definition of androgen deficiency (AD) is still very controversial in medicine. AD can be defined purely in biochemical terms using testosterone levels below the range of normal, or only using signs and symptoms. The problem with the first method is that not all men with low testosterone levels have symptoms. Symptom questionnaires may have poor accuracy due to the non-specific nature of the symptoms associated with AD. A combination of the blood testosterone levels in conjunction with signs and symptoms to establish whether a trial of testosterone therapy is indicated are necessary for the greatest interpretation and treatment.
Testosterone can be administered by a topical cream, gel or injection. After more than 10 years of conducting TRT, I prefer the injection form of therapy. I have personally used testosterone for 15 years, initially with cream, but using injections for the last 8 years. A weekly self-administered intramuscular injection can provide reliable blood levels of Free Testosterone. Timing of blood collection is critical to the accuracy of levels and dosing adjustments. This method is cost effective as injectable testosterone has been available for more than 40 years and is generic and therefore low in cost.
In my opinion, a TRT program should monitor estradiol levels and the prescription of aromatase blockers, if indicated. TRT should be a collaborative effort between the patient and physician as the physician will ensure proper levels and ratios of the hormonal treatment and the patient is responsible for ensuring that there is an improvement in symptoms that prompted the TRT. It can be challenging for men to be sure there is a benefit to the treatment. I will often suggest a trial of TRT discontinuation once levels of testosterone and estrogen are optimized. Many men will not be sure of a difference in how they feel as levels are gradually normalized when starting TRT. A stop in the TRT will often remind the man of the symptoms that had prompted the treatment in the first place. In this way, we can be sure the benefits in symptom reduction outweigh the disadvantages of weekly injections. A return of symptoms would prompt a restart of the TRT and ensure the patient is certain of the advantages for symptom improvement. Men that notice no difference in symptom control with TRT should not continue treatment. The health promotion benefits of TRT are still too uncertain to promote this treatment other than for symptom control.
There is evidence that restoration of testosterone levels in men can reduce the chances of developing heart disease, stroke and death. A large 2015 study in the European Heart Journal provided evidence for a reduction in heart attacks in men where men’s testosterone levels were returned to the normal range. 80,000 male veterans with documented low testosterone levels were divided in to 3 groups
- No treatment.
- Treatment without monitoring testosterone levels.
- Treatment with monitoring of testosterone levels to ensure normalization.
Treatment group 3 showed the greatest benefit for treatment. In this group, there was a 24% reduction in heart attack, 36% reduction in risk of stroke and 56% reduction in the risk of all cause death. This study gives reassurance that TRT does not increase the risk of cardiovascular disease. It is important to realize that these study outcomes are not frequent and use of percentages to document reduction can overstate the overall benefit. I do not believe the evidence is sufficient to warrant promotion of TRT to reduce cardiovascular disease. It does give me comfort to support the belief that I am not increasing the risk of heart disease while improving the overall quality of life for patients.
Previously, TRT has been thought to be a potential cause of prostate cancer. This belief in medicine has always been strong and deeply rooted. Dr. Abraham Morgentaler, a urologist at Harvard Medical School, wrote an excellent book on the subject of TRT and prostate cancer – ‘Testosterone For Life’. It is humorous and insightful and debunks many of the myths surrounding TRT and prostate cancer. Dr. Morgentaler found low testosterone to be a significant risk factor for the development of prostate cancer and the evidence clearly shows that TRT is safe for the prostate gland.
In summary, TRT can improve the symptoms associated with andropause such as fatigue, depression, poor concentration and erectile dysfunction. I believe that a TRT program should be conducted with medical supervision and monitored with blood levels of testosterone and estradiol. TRT administered in this fashion can often improve the quality of life of men as they age.
By Dr. Ron Brown – True Balance Longevity Med Spas