About $1.6 billion in testosterone prescriptions were sold in the United States last year, more than double the amount in 2007, according to Bloomberg L.P. Men in their 50s and 60s, many of them exhorted by widely aired TV commercials to talk to their doctors about a “treatable condition” known as "Low-T," account for the bulk of these sales.
The TV spots have come under fire by physicians and others for attempting to “transform the natural aging process into a disease state,” as Dr. Craig Bowron recently wrote on Slate.com. The ads generally urge men to seek a prescription if they don’t feel like their old selves. “Don’t have the hots for hoops with your buddies?” one campaign asks. In other words, are you getting older?
Why Testosterone Levels Drop
Testosterone is naturally produced in the male body by the testicles. Signs of low testosterone may include lack of interest in sex or enlarged breasts, although there may be other causes for those conditions as well. Untreated, low testosterone can lead to a loss of body hair and muscle bulk, and osteoporosis (thinning of the bones). Low testosterone can be caused by testicular injury or infection, radiation or chemotherapy treatments, chronic conditions, like diabetes or liver or kidney disease, and certain genetic or hormonal disorders, according to the Endocrine Society.
A doctor can measure your testosterone level with a blood test. For a man in his 60s, a normal reading would be between 300 and 720 nanograms per deciliter of blood (ng/dL). (A man in his 20s could be expected to have a level of 300 to 1080 ng/dL.) If your count is below the normal range, your doctor can refer you to an endocrinologist, who would look into potential causes. If treatment is determined to be beneficial, it would likely include a prescription testosterone supplement, which might take the form of an injection, patch or gel.
We know that men’s testosterone levels tend to drop as they age. Researchers have long believed that this decline was a natural part of aging, although new findings indicate that testosterone dips may also be, at least in part, the result of non-age-related factors, as well as lifestyle choices. For example, a recent five-year study of nearly 1,400 Australian men with an average age of 54 found a strong link between obesity and depression and lower testosterone levels in the group. That finding has led some to wonder if low testosterone might be better treated with diet or psychotherapy before prescribing supplements.
Other studies have found that testosterone levels can be more fluid, or even quirky, than imagined, plummeting when men become new dads or even when their favored presidential candidate loses the race.
The Attraction, and Risks, of Supplements
Still, for many fiftysomethings who feel their energy flagging and discover they have a low testosterone level, reversing the tide with a boost of male hormones may sound appealing — and the supplements usually deliver results. They can help boost muscle mass and enhance energy and libido. But there are risks as well. Supplements can have side effects, including sleep apnea and enlarged breasts and prostate. (Men with prostate cancer or high risk factors for prostate cancer are generally discouraged from taking testosterone supplements.)
A study published in the New England Journal of Medicine raised another potential risk: cardiovascular problems. The study tracked 200 men age 65 and older whose health concerns included difficulty walking and high blood pressure. The patients were prescribed a testosterone gel, which delivered significant improvement in their ability to lift weights and climb stairs, compared to men using a placebo. But the men also had four times the risk of chest pain, heart attack and stroke. The incidence of cardiovascular ailments was so high that the trial was called to a halt.
Given the apparently expanding list of known testosterone supplement risks, are they worth the trouble?
Geriatrician Thomas Gill, director of the Yale School of Medicine’s Program on Aging, is not ready to give up on the supplements. “It would be sending the wrong message if the recommendation is that all men stop treatment because of this study,” he says. He points out that it was the first (and, so far, only) trial to show an association between testosterone gel and heart problems. Moreover, the research was on a relatively small number of especially frail men who were given unusually high doses of the hormone. “If I were an older male without prior cardiovascular disease,” he says, “I wouldn’t lose much sleep over this one study.”
Detecting a link between testosterone gel and cardiovascular disease was not the mission of the New England Journal of Medicine study, but it raised enough questions that other researchers are now investigating it directly. Gill and his research team are working with the National Institutes of Health on a larger study of 800 men, known as “The T Trial,” designed to examine the effects of testosterone on the heart. “We are setting things up to carefully evaluate the cardiovascular effects of testosterone,” he says, adding that he will have results in about three years.
But Dr. Shalender Bhasin, chief of endocrinology at Boston University School of Medicine and a co-author of the New England Journal of Medicine study, believes we know enough already to at least consider testosterone supplements with a more critical eye. Doctors already know, for example, that water retention, which can put a strain on the heart and is associated with blood clots and tissue inflammation, is a potential side effect. So the link to cardiovascular disease is not especially surprising.
In general, Bhasin says, doctors should give more information to patients considering the treatments. For example, he says, "doctors don’t tell you that testosterone supplements may end up a long-term proposition." When men begin using a supplement, he explains, they typically lose the ability to create testosterone on their own. So if a health problem should arise that forces them to stop taking the supplements, it may take months or years to recover the ability to create adequate levels of testosterone naturally, during which time they may experience withdrawal symptoms like poor mood and low vitality.
“I find it very distressing that testosterone is used in middle-aged men — when we don’t know whether it’s even safe — for something that may be a normal physiologic adaptive mechanism to aging," he says.
Both experts agree that men with a history of heart attack or stroke should steer clear of testosterone supplements. They also agree that there are scenarios in which the benefits of testosterone therapy nearly always outweigh the risks, like hypogonadism, a disease in which the body produces little or no hormone due to poorly functioning testes or pituitary or hypothalamus glands.
Many men report feeling stronger and more vital, and thinking more clearly, on testosterone supplements. That may make it worth the risk if your testosterone count is low. But you should also give some thought to why you're pursuing a supplement, and its risks, despite what the late-night commercials promise.