Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
27 July 2005

MALE HORMONE THERAPY

            The topic of androgens, male hormones, testosterone, and “steroids” has received a great deal of attention in the media recently.  Stories of high school athletics using “steroids” to build strength and muscle has been spectacularized regarding the side effects of acne, over aggression and even psychosis that can develop.  Because of these problems, the Food and Drug Administration has placed testosterone and it analogs in the same class as narcotics in regard to restrictions.

            There is an adage in medicine that “potent products have the potential for potent side effects”.  When the potent product is very desirable and is highly effective, the potential for abuse and amplification of side effects is even bigger.  Thus, the male hormone products being very effective and very potent must be respected in regard to the potential side effects.

            But there is another side of the story that is under appreciated and probably under utilized.  In a recent study involving 2,162 patients in 95 primary care centers, abnormally low testosterone levels were found in 39% of the men examined.  In other words, these men were making significantly less testosterone than the normal.  The striking finding of this study was that these men had a much higher incidence of high blood pressure, diabetes, and high blood cholesterols.    Judging by what the basic hormonal effects of testosterone are, this was really not a surprise but had not been previously published.

            The characteristics of a eunuch that results from prepubertal castration were known to the  ancients.  But it was not until 1935 that testosterone was isolated and synthesized so that the effects of the pure chemical compound could be determined.  Over the years since then, it was clearly recognized that testosterone decreases abdominal fat, builds skeletal muscle, improves muscle strength, and maintains sexual health.  Recent studies have shown that maintaining normal male sexual hormone levels is associated with a decreased incidence of cardiovascular side effects from diabetes, hypertension and hypercholesterolemia.

            There is an emerging idea that just as women use estrogen to prevent various undesirable symptoms that result from hormonal deficiency, men might do the same thing with testosterone therapy.  One would logically ask what the down side of this idea might be.  Potential side effects include an increased blood count.  Testosterone stimulates the bone marrow to make more blood and the blood count can actually come out higher than normal.  This can cause blood clot problems although it has not been reported as a major side effect in men using testosterone replacement.  Secondly, testosterone can cause fluid retention and ankle swelling.  In some individuals who are more sensitive to the drug, this can be a significant complication.

            Thirdly, testosterone is not thought to cause prostate cancer but it will fan the flames of one that is already present and make it grow more rapidly.  Thus, men with prostate cancer should not be using testosterone.  Fourth, the abuse potential is always present; using more than the recommended normal replacement is a temptation for some individuals.  This should be strongly discouraged and prescription stopped if the man seems to be accelerating his dosage.

            With the above considerations, what are the uses of testosterone for legitimate health considerations?

            First, testosterone injections provide an excellent stimulant for appetite and muscle strengthening in our elderly population who are losing weight, have a very poor appetite and becoming progressively weak.  In this situation, testosterone can serve a very useful purpose in re-establishing appetite and converting the increased food intake into muscle and better strength.  Ironically, testosterone works every bit as well in women with this problem as it does in men.  The dosage can be very modest and have a very beneficial effect.

            Secondly, for men age 45 and over who are tending to become flabby, gain weight, and become less physically strong, a check of the serum testosterone level might reveal low values.  When this occurs,  a replacement of the hormone to normal levels can be very beneficial in reducing the abdominal fat deposits, increasing muscle strength and allowing greater physical activity.  This does not mean that these men should be taking abnormal amounts of testosterone.  Rather it means that replacement of the amount of hormone to achieve normal levels is indicated. It does not mean abnormally high levels associated with side effects should be allowed.

            Thirdly, there are a variety of relatively rare types of anemia that are highly benefited by the use of replacement level testosterone.  These are special cases.

            Lastly, there is a relatively rare condition called hypopituitarism in which the pituitary gland in the brain fails.  When this occurs, the signal to the body to make testosterone is lost and normal physiologic replacement is an indicated step to re-establish normal function.

            What is the right dose for replacement therapy?  On the average, men make about 10 mg of testosterone per day.  This amounts to about 300 mg per month.  The use of injected testosterone is not as efficient as testosterone made by the person’s body.   This is primarily because of delivery methods and the injected hormone being excreted more quickly than the natural hormone.  Present estimates are that 100 mg injected every 7-10 days replaces the testosterone levels back to the normal range with associated improvements described above.

            Over the past many years, there have been attempts to find an oral preparation that is effective and safe.  Unfortunately, methyl testosterone which is an oral preparation is associated with development of cancer of the liver in some few individuals.  Thus the oral replacement is not a recommended method of testosterone replacement.  As a result, injectable testosterone which is slowly released is the best replacement method available.  This requires an injection every 7-10 days.  Many individuals can do this on their own at home just as individuals inject insulin but it is somewhat more bothersome than simply taking a pill as the lucky women get to do.

            The healthcare providers at your local clinics are aware of the above considerations.  They are highly respectful of the potential side effects and abuse of this medication but they are also aware of the potential benefits of improved function and even lifesaving potential of this very powerful hormone.