The siren call of testosterone supplementation

Testosterone supplementation is a booming business. Direct-to-consumer marketing is expanding, touting the many benefits of testosterone supplements for aging men. If you’re male, over the age of 40, and have experienced tiredness, decreased muscle mass, lower libido, or increasing weight, you are a prime target for the testosterone supplement manufacturers.

Two recent articles provide interesting context and perspective for clinicians encountering male patients who report the above listed symptoms and request testosterone as a treatment. On August 11, JAMA published an industry-sponsored study whose primary purpose was to look at whether testosterone supplementation may accelerate atherosclerosis. This was done by looking at changes in carotid intimal thickness and coronary calcium scores over a three-year period in men given testosterone compared to those given placebo. This brief study found no significant differences in the two measures, leading the authors to conclude testosterone supplementation does not accelerate atherosclerosis.

However, there are three obvious problems with this JAMA study. First, the three year time frame is quite short, if the goal is to assess differences in development of atherosclerosis. Second, the study looked only at secondary endpoints rather than actual cardiovascular events. Third, the study looked at whether men given testosterone had better sexual function or improved quality of life scores compared to men given placebo. The result: no difference between the two groups in these measures.

The second article was a perspective piece which appeared in the August 20 NEJM. It pointed out that 28% of men with a new-start prescription for testosterone have never had a testosterone blood test performed. Presumably many of these men are being prescribed testosterone for symptoms that many, if not most, men get as they age. The article also points out that the issue of whether testosterone supplementation may yield adverse cardiovascular side effects has not been resolved. The authors caution against the proliferating use of testosterone for the normal age-related decline in testosterone levels.

We want to reassure readers that we are not on a general crusade against testosterone medication. There are objective, established clinical conditions in which the drug can significantly improve a person’s health. But it is abundantly clear that testosterone medication is being too widely used for men who are experiencing the usual vagaries of the aging process. While it can be hard for primary care clinicians to resist the siren call of testosterone supplementation, it is important to educate our patients on normal aging and the potential risks of trying to find a fountain of youth.

Richard Fleming, MD

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