RX for Change: The Low-Down on Low-T (or Menopause for Men)

Article taken from September/October Newsletter 2013

Does the man in your life have “Low-T” (low testosterone) Syndrome? Oh, wait; make that “the men in your life” — chances are any of the men you know over age 40 qualify for a diagnosis.

Symptoms supposedly associated with “Low-T” Syndrome are vague and overlap with symptoms of aging, like fatigue, reduced libido, and reduced body hair. Most men (and, for that matter, women) would fail the Low T self–assessment tests that are available on-line that include questions like “Do you have less energy than you did five years ago?” and “Do you ever get headaches?” and “Do you fall asleep after dinner?”

To address this “problem,” testosterone in gels, patches, and roll-ons is now being promoted to middle-aged and older men as a virility-enhancing, anti-aging, and disease preventing panacea. The promotion of “Low-T” to consumers eerily parallels the promotion of “estrogen deficiency” to women and prescribers. In the 1990s, 20 percent of menopausal women were taking “estrogen replacement therapy.” The NWHN was one of very few organizations that vociferously opposed the concept of medicating women during the menopausal transition, an extremely unpopular stance. All NWHN veterans can attest to the sense of being the skunk at the picnic at women’s health meetings, where the benefits of hormones for preventing heart attacks, strokes, dementia, and wrinkles were extolled without scientific proof.

We were completely vindicated when the Women’s Health Initiative (a large, long-term, Federally-funded randomized controlled trial) found that menopause hormone therapy increased the risk of breast cancer, blood clots, dementia, and cardiovascular disease.1 Prescriptions for hormone therapy plummeted — along with breast cancer rates.2

Now, pharmaceutical companies are targeting men, the women who influence them, and health care providers who can prescribe testosterone (including physician assistants and nurse practitioners). Testosterone manufacturers are flooding TV with ads. Abbott (now AbbVie), which markets the bestselling Androgel, spent $20.8 million on testosterone ads in 2011 alone.

Appallingly, AbbVie also sponsors a website, Drive for Five, (http://www.driveforfive.com) that describes five risks to men’s health, including high cholesterol, high blood pressure, high blood sugar, high PSA levels, and — last but not least — low testosterone levels. It’s outrageous to try to make men think their testosterone level is as important as possible hypertension or diabetes!

Steve Braun, a writer hired to generate articles supporting the use of testosterone therapy in various publications, described ghostwriting an article to appear under an endocrinologist’s byline, for Life After 50 magazine. The article included a “Facts for Women” sheet that encouraged women to diagnose their male partners and encourage them to seek medical attention.3

One of us is a hospitalist working in a community hospital, where a review of medications being taken is a part of a patient’s admission to the hospital. Over the last five years, we have noted a rising percentage of men between the ages of 40 and 90 who report that they take testosterone. When asked why they were prescribed testosterone, the answers are often quite vague and include responses along the lines of: “My doctor told me it would increase my energy,” or “My provider told me it would increase my sex drive and make me feel better, overall.”

Testosterone manufacturers have flooded medical journals with articles meant to convince physicians about the epidemic of Low-T (called “late-onset hypogonadism” in medical literature because it sounds more science-y). Prescribers are being urged to test for Low T, and men are being urged to ask for the test.

But there is little rationale for testosterone testing. Men who were born without testicles, or whose testicles are damaged, have genuine testosterone deficiency that should be treated. For men with normal testicles, however, testosterone levels peak in their 20s and then decline gradually; after age 40, levels decline by about 1-2 percent every year.4 At every age, though, there’s a wide range of normal testosterone levels. Testosterone levels also change during the day (they’re highest in the morning) and can vary on different days; for example, soccer fans have higher testosterone levels during the World Cup than on other days.5 No consistent relationship between symptoms and testosterone levels has been proven.6

Even if men don’t need testosterone, does it make them feel better? It’s hard to say, especially as conditions like fatigue and low libido improve with placebos. If testosterone were just an expensive placebo, however, we wouldn’t be so concerned about it. Our concern is that testosterone given to men who don’t need it may hurt them. Testosterone can increase the growth of prostate cancer and worsen congestive heart failure.7 And, although testosterone is being touted to prevent cardiovascular disease, it actually seems to increase risks (again, echoes of menopausal hormone therapy).

A meta-analysis of 2,994 men in 27 trials identified 180 heart attacks and other cardiovascular-related events among men taking testosterone. Testosterone therapy significantly increased the risk of cardiovascular events; the risk identified varied depending on whether or not testosterone manufacturers funded the study. Studies that were not industry-funded found the risk of a cardiovascular-related event in men getting testosterone therapy was doubled; trials funded by the pharmaceutical industry found no increased risk!8

All this promotion is working. Sales of testosterone products have risen 90% over the past 5 years. In 2011, global sales of testosterone products reached $1.9 billion and are expected to reach $5 billion by 2017.9,10

Low-T Syndrome is being marketed as a disease for men in the same way that menopause was marketed as a disease for women: by preying on our fear of aging and selling hormones as an elixir of youth. Hormones are powerful compounds that affect many of the body’s organs, and there’s no such thing as a harmless hormone. Let’s take a lesson from menopausal hormone therapy. Don’t believe industry-funded research, and don’t let the men in your life take a dangerous hormone on the basis of hype and hope.

 


References:

1. Fugh-Berman A, Pearson C, “The overselling of hormone replacement therapy,” Pharmacotherapy 2002; 22(9):1205-8. Fugh-Berman A, Scialli A, “Gynecologists and estrogen: An American love affair,”Perspectives Biol Med 2006; Winter: 115-130. Available online at: http://fugh-berman.com/files/Perspectivespro.pdf

2. Zbuk K, Anand SS. “Declining incidence of breast cancer after decreased use of hormone-replacement therapy: magnitude and time lags in different countries,” J Epidemiol Community Health 2012; 66(1):1-7. doi: 10.1136/jech.2008.083774. Epub 2011 Aug 28.

3. Braun SR, “Promoting ‘Low T:’ A Medical Writer’s Perspective,” JAMA Intern Med. 2013;():1-4. doi:10.1001/jamainternmed.2013.6892.

4. Feldman HA, Longcope C, Derby CA, et al., “Age trends in the level of serum testosterone and other hormones in middle-aged men: longitudinal results from the Massachusetts male aging study,” J Clin Endocrinol Metab 2002; 87:589–598.

5. van der Meij L, Almela M, Hidalgo V, et al., “Testosterone and cortisol release among Spanish soccer fans watching the 2010 World Cup final,” PLoS One 2012; 7(4):e34814. doi: 10.1371/journal.pone.0034814. Epub 2012 Apr 18.

6. Huhtaniemi I, Forti G, “Male late-onset hypogonadism: pathogenesis, diagnosis and treatment,” Nature Reviews Urology 2011; 8:335-344.

7. Abbott Labs. (2011). Androgel®. FDA/Center for Drug Evaluation and Research. Accessed August 13, 2012.

8. Xu L, Freeman G, Cowling BJ, et al., “Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials,” BMC Med. 2013; 11:108. doi: 10.1186/1741-7015-11-108.

9. Perrone M, “Testosterone Marketing Draws Skepticism,” Associated Press, 09/09/2012.

10. Pettypiece  S, “Are Testosterone Drugs the Next Viagra?” Businessweek, May 10, 2012. Available online at: http://www.businessweek.com/articles/2012-05-10/are-testosterone-drugs-the-next-viagra