Starting around age 30, men's testosterone levels begin to drop. By the time men are between the ages of 40 and 55, they begin to experience a phenomenon similar to the female menopause. Unlike women, men do not experience a clear cut marker such as the cessation of menstrual cycles to mark the transition. The body changes occur more gradually in men and may include changes in attitude, mood, fatigue, loss of energy, loss of sex drive, memory loss, obesity, loss of muscle and osteoporosis. The mood changes are often confused with depression. These symptoms come on long before the male loses his sex drive or become impotent. Andropause is not a benign condition. Men with low testosterone are 65% more likely to die than a man with normal testosterone.
An estimated 2-4 million American men are low on testosterone. Testosterone levels in males peak at age 17 and declines 1% per year thereafter, as men get older their levels drop on average 1.5% per year. A middle age male can therefore have a testosterone level 40% below his peak in sex binding globulins, which make the lowered testosterone that is present even less effective. By age 50, 20% of men have a testosterone deficiency, and by age 80, 50% of men are low on testosterone even using old standards.
There is no evidence that testosterone replacement therapy in males causes prostate cancer or prostate enlargement. In fact, some Urologist-Oncologists say that testosterone may decrease the incidence of prostatic hypertrophy and prostate cancer. Dr. Borgardt uses topical testosterone replacement as an essential part of its Hormone Replacement Therapy (HRT) program for both men and women based on the patient's total and free testosterone levels and their levels of sex binding globulins. Most men can correct their testosterone deficiency using a topical cream applied to the arm once or twice a day.
Among men with androgen deficiency, dispensed testosterone prescriptions were associated with a lower risk of cardiovascular outcomes over a median follow-up 3.4 years. Jama Intern Med 2017;17
Since the 1940s data has shown that men with low testosterone have a higher incidence of coronary artery disease, stroke, and death. Men with low testosterone have 88% increased mortality compared to men with a normal testosterone (1). Men with coronary artery disease have significantly lower testosterone levels than men without coronary artery disease (2). Animals surgically castrated show accelerated atherosclerosis that is reversed by testosterone replacement therapy (3,4). Men treated with testosterone suppression therapy show a 16% increased risk of cardiovascular disease death from myocardial infarction (5). Castrated men show similar results with a two fold increase in cardiovascular mortality (6). Meta-analysis of 19 prospective studies showed a significant inverse relationship between testosterone and coronary disease in men older than 70 years (7). These studies clearly show that men with low testosterone die of heart disease, and if you lower the testosterone of normal men they die of heart disease. The current standard of care is to treat men with testosterone assuming that correcting testosterone levels will reverse this cardiovascular and stroke mortality effect.The recent controversy started in 2010 when a study showed that frail elderly men would improve their activity level when given testosterone, however the study was stopped early because of increased coronary artery disease in the men treated with testosterone (8). This was a small study, and the reason for the increased heart attacks in the treated men may have simply been from their increased activity level. Every winter frail elderly men have heart attacks while shoveling snow. A more recent data analysis of the VA computer records showed that men given a prescription for testosterone after their angiogram had a higher incidence of heart attacks and strokes (9). Unfortunately the study did not document that the men actually took the testosterone, or why one group of men was given testosterone while the others were not. This type of data analysis is very unreliable. Prior scientifically performed studies have documented decreased coronary artery symptoms in men treated with testosterone. Neither of these new studies has given us the proof that physicians need to advise our patients regarding testosterone therapy. They do however point out the need for a real scientific study to look into the possible risks.The frail male and VA prescription after angiography publications directly contradict the numerous studies that came before them. A 2004 randomized placebo controlled trial (the gold standard for medical trials), found testosterone replacement therapy improved symptoms and exercise capacity in men with heart failure (10). Another study of testosterone replacement in men with angiographically proven coronary artery disease showed decreased angina with exercise persisting for the study period of 1 year (11). There are numerous other studies showing improvement in diabetes, cardiac arrhythmias, cardiac risk factors, etc. while on testosterone. The most recent FDA statement regarding this controversy: “It has not been firmly concluded that approved testosterone treatment increases the risk of stroke, heart attack, or death. Patients are advised to not discontinue their testosterone therapy without discussing with their healthcare provider.”Low serum testosterone and mortality in male veterans. Arch Intern Med. 2006 166:1660-52 Anti-ischemic effect of testosterone in men with coronary artery disease. Circulation 1999 99:1666-703 Natural androgens inhibit male atherosclerosis. Circ Res. 1999 84:813-194 Physiologic testosterone replacement therapy attenuates fatty streak formation and improves HDL cholesterol in the Tfm mouse: an effect that is independent of classic androgen receptor. Circulation. 2007 116:2427-345 Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol. 2006 24:4448-566 Androgen deprivation therapy for localized prostate cancer and the risk of cardiovascular mortality. J Natl Cancer Inst. 2007 99:1516-247 Endogenous testosterone and cardiovascular disease in healthy older men: a meta-analysis. Heart 2011 7:870-58 Adverse events associated with testosterone administration. N Engl J Med. 2010 Jul 8;363(2):109-229 Testosterone therapy associated with higher risk of death, heart attack, or stroke. JAMA 2013, Nov 6.10 Testosterone treatment for men with chronic heart failure. Heart 2004 90:446-711 Long term benefits of testosterone replacement therapy on angina threshold and atheroma in men. Eur J Endocrinology 2009 161:443-9
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