Testosterone Therapy: The Superman Fallacy

Testosterone therapy can help men who suffer from low energy or a lack of sexual desire. However, it’s being pitched to men who don’t need it. Further, the safety of long-term testosterone use is unclear.

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Eric Hansen doesn’t have to have a calendar to know when he needs another shot of testosterone. Over a matter of days, he falls into what you might call an Incredible Sulk.

“I’m grumpy, I have low energy levels, and I just want to sit around and watch TV,” says Hansen, who is a 52-year-old aircraft production worker. His testicles were removed when he was in his 20s because of cancer. Now, after he gives himself an injection to restore his levels of testosterone (his body barely produces the hormone on its own), “things get brighter and life gets grander, and the sexual energy does increase,” he says.

A low level of testosterone, or low T, can affect a man’s physical appearance, mood and sex drive, according to National Institutes of Health (NIH), which estimates that about 5 million U.S. men have low T. Symptoms of low T include fatigue, irritability, sleep apnea, loss of sexual desire, erectile dysfunction and fewer erections first thing in the morning.

That testosterone can help to relieve those conditions isn’t in dispute. However, whether you should use supplemental testosterone is unclear. Unfortunately, the makers of supplemental testosterone and the clinics that dispense it aim to convince men that treatment for low T applies to more men than just those who have a clear medical need. Internet, print and TV ads reinforce the message that by taking supplemental testosterone, many men can receive the boost that Hansen experiences every 2 weeks.

Six doctors who were interviewed by Consumers Digest believe that supplemental testosterone is overused and touted wrongly by some doctors and clinics as a 21st-century fountain of youth. “The crazy thing is that testosterone somehow got labeled as a rejuvenation drug,” says Dr. Darius Paduch, who is a urologist and the director of Sexual Health & Medicine at Weill Cornell Medical College. “We know that it’s not. I tell patients that I’m almost 50, and if there was a rejuvenation drug, I’d take it first.”

Lisa Schwartz and Steven Woloshin, who are professors at The Dartmouth Institute for Health Policy & Clinical Practice, address the issue in a commentary on a study that was published August 2013 in Journal of the American Medical Association (JAMA) Internal Medicine. They say marketing testosterone therapy is an “uncontrolled experiment, which invites men to expose themselves to the harms of a treatment unlikely to fix problems” that might be wholly unrelated to testosterone levels.

Despite those cautions, testosterone therapy is rising. The JAMA study reported that the use of testosterone therapy among men who are age 40 and older rose to 2.9 percent in 2011 from 0.8 percent in 2001. Experts say the 2011 level likely is higher than 2.9 percent, because uninsured men weren’t tracked.

SPECIFIC CONDITIONS. Food and Drug Administration and doctors agree that men might have to boost their testosterone levels if their testicles were injured or removed or if they had testicular cancer. FDA says tumors in the pituitary gland or the hypothalamus (both in the brain) also can disrupt testosterone levels, as can chemotherapy or radiation treatments for cancer, and certain infectious diseases. Men who have an extra X chromosome also are candidates for testosterone therapy, says Dr. Bradley Anawalt, who is an endocrinologist and a professor of medicine at University of Washington. Most of the men who are in that group have, or eventually have, low T, he says.

In September 2014, an advisory panel to FDA overwhelmingly advised the agency to continue to recommend that doctors prescribe testosterone therapy only to men who have low T as a result of those specific medical conditions. As of press time, FDA hadn’t decided what to recommend, although the agency typically follows its advisory panels’ suggestions.

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Meanwhile, doctors continue to prescribe testosterone to whomever they wish, and they’ll be able to continue doing so even if FDA follows its advisory committee’s suggestion. That’s because the advisory panel’s suggested restriction wouldn’t preclude doctors from prescribing supplemental testosterone “off label.”

Granted, medical conditions aren’t the only cause of low T. According to Anawalt, the use of medications, such as corticosteroids and heavy-duty opioid painkillers, also can cause low T. Further, men who are at least 60 are most likely to have low T because of aging, obesity or poor health, Anawalt says. However, it’s unclear whether these men would benefit from testosterone therapy, he says.

Dr. Tobias Köhler, who is a urologist and an associate professor at Southern Illinois University School of Medicine, says a high rate of diabetes and obesity explains why the use of testosterone therapy increased. According to Centers for Disease Control and Prevention, the number of U.S. men ages 45–64 who have diabetes increased to 12.4 percent in 2011 from 9.6 percent in 1999. Although the rate of obesity has remained steady in the past decade, a February 2014 report in JAMA estimated that 72 percent of U.S. men who are 21 or older are overweight or obese. As poor health or excess weight prompts the earlier onset of, or magnifies, the signs of aging—less energy, lower sex drive—more men might look for easy fixes, Köhler says.

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