Defending Testosterone, Debunking the Myths
The testosterone/CV risk story has given apparent legitimacy to several erroneous notions about testosterone. For the sake of medical science, I wish to briefly address several of these.
Myth 1: Pharmaceutical marketing drove the increase in testosterone prescriptions.
The data suggest otherwise. In 2010, during the steepest increase in testosterone prescriptions, no testosterone product was within the top 20 most-advertised drugs. For those of us who teach at continuing medical education events, it was clear that the rise in prescriptions coincided with an increased awareness of testosterone deficiency and a reduced fear about prostate cancer among providers.
Myth 2: Testosterone is overprescribed.
From 1996 to 2007, an FDA website (now defunct) asserted that only 5% of men with hypogonadism receive treatment, while estimating that the size of the hypogonadal population in the United States was about 2-4 million. Current data indicate that about 2 million men are being treated with testosterone. Thus, it is hard to argue that testosterone is overprescribed.
Myth 3: Treatment of hypogonadism should be based on a known cause.
Some clinicians have suggested that testosterone treatment should be initiated only when there is a documented cause for hypogonadism, such as a pituitary tumor, but not when low testosterone is a consequence of aging.
Deficiencies of hormones, such as testosterone, produce certain symptoms. The effect is the same whether an underlying cause is identified or not.
Imagine limiting antihypertensive therapy to the minority of men with known causes. This makes no sense.
Should we deny treatment for diabetes, arthritis, and cataracts because they are more prevalent with age?
With respect to age-related testosterone deficiency, let us recognize that many common medical conditions are age-related, including diabetes, arthritis, cataracts, coronary artery disease, and cancer. Should we deny treatment for these too because they become more prevalent with age? Illogical.
Myth 4: The Women's Health Initiative (WHI) taught us that hormonal treatments can be dangerous.
Testosterone is not estrogen, and men are not women. To conflate the two is unscientific.
In any case, readers may be surprised to learn that 2013 follow-up data from the WHI revealed significantly fewer cases of invasive breast cancer among women who took estrogen alone compared with women who took placebo. Once headlines assert risks, it can take years for the true evidence to be acknowledged.
Myth 5: Testosterone is prescribed inappropriately.
I have yet to see any data to support this, and I question whether any overuse of testosterone products is different from that seen with other pharmaceuticals. Critics often point to studies showing that 25% of testosterone prescriptions were not preceded by a serum testosterone test. As an author of one such study, I can state that the true rate of testing is unknown, because the results reflect computerized insurance data, which are prone to error, and no actual charts were examined.
Myth 6: The benefits are unproven.
There is level 1 evidence that testosterone therapy improves libido, erections, and mood; it also increases muscle mass and bone density; and it reduces fat mass. These benefits are seen every day in clinical practice.
Indeed, one only needs to treat five symptomatic men with low testosterone values to become convinced: two will thank the physician profusely for restoring their sexuality and vitality, another two will report solid benefits, and one will not respond.
Toppling Testosterone Myths and Misperceptions
The testosterone/CV risk story has given apparent legitimacy to several erroneous notions about testosterone. For the sake of medical science, I wish to briefly address several of these.
Myth 1: Pharmaceutical marketing drove the increase in testosterone prescriptions.
The data suggest otherwise. In 2010, during the steepest increase in testosterone prescriptions, no testosterone product was within the top 20 most-advertised drugs. For those of us who teach at continuing medical education events, it was clear that the rise in prescriptions coincided with an increased awareness of testosterone deficiency and a reduced fear about prostate cancer among providers.
Myth 2: Testosterone is overprescribed.
From 1996 to 2007, an FDA website (now defunct) asserted that only 5% of men with hypogonadism receive treatment, while estimating that the size of the hypogonadal population in the United States was about 2-4 million. Current data indicate that about 2 million men are being treated with testosterone. Thus, it is hard to argue that testosterone is overprescribed.
Myth 3: Treatment of hypogonadism should be based on a known cause.
Some clinicians have suggested that testosterone treatment should be initiated only when there is a documented cause for hypogonadism, such as a pituitary tumor, but not when low testosterone is a consequence of aging.
Deficiencies of hormones, such as testosterone, produce certain symptoms. The effect is the same whether an underlying cause is identified or not.
Imagine limiting antihypertensive therapy to the minority of men with known causes. This makes no sense.
Should we deny treatment for diabetes, arthritis, and cataracts because they are more prevalent with age?
With respect to age-related testosterone deficiency, let us recognize that many common medical conditions are age-related, including diabetes, arthritis, cataracts, coronary artery disease, and cancer. Should we deny treatment for these too because they become more prevalent with age? Illogical.
Myth 4: The Women's Health Initiative (WHI) taught us that hormonal treatments can be dangerous.
Testosterone is not estrogen, and men are not women. To conflate the two is unscientific.
In any case, readers may be surprised to learn that 2013 follow-up data from the WHI revealed significantly fewer cases of invasive breast cancer among women who took estrogen alone compared with women who took placebo. Once headlines assert risks, it can take years for the true evidence to be acknowledged.
Myth 5: Testosterone is prescribed inappropriately.
I have yet to see any data to support this, and I question whether any overuse of testosterone products is different from that seen with other pharmaceuticals. Critics often point to studies showing that 25% of testosterone prescriptions were not preceded by a serum testosterone test. As an author of one such study, I can state that the true rate of testing is unknown, because the results reflect computerized insurance data, which are prone to error, and no actual charts were examined.
Myth 6: The benefits are unproven.
There is level 1 evidence that testosterone therapy improves libido, erections, and mood; it also increases muscle mass and bone density; and it reduces fat mass. These benefits are seen every day in clinical practice.
Indeed, one only needs to treat five symptomatic men with low testosterone values to become convinced: two will thank the physician profusely for restoring their sexuality and vitality, another two will report solid benefits, and one will not respond.
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