Why the mounting testosterone controversy won’t make me take my patients off T

It seems almost every treatment I’ve ever advocated for—from daily vitamins to low-carbohydrate diets—comes under attack at some point. And every time, I’ve come out on the right side of the argument.

That’s why I didn’t bat an eye at the latest controversy over testosterone replacement in men. Despite the growing number of headlines it’s grabbed over the last several months.

As you may recall, testosterone therapy is something I promote fiercely. (In fact, I dedicated an entire article to the subject back in November 2012.) And I have been testing both men and women for low levels of testosterone for at least 15 years.

The incidence of low T is, quite frankly, astounding. And invariably, my patients feel more alive and more energetic with testosterone replacement. It clears their heads. Doubles their motivation. And of course, supercharges their sex drive.

But as you may also have heard, a lot of health professionals have been questioning the value of this practice. The FDA recently announced plans to conduct a formal review of the heart risks associated with popular testosterone drugs. And shortly after, the Endocrine Society released a statement insisting that these treatments should carry a warning for older men.

So I’d be remiss if I didn’t address this controversy directly. And also explain why it’s not going to change the way I treat my patients at all.

What the latest statistics mean…for some men

First things first. Let’s take a look at some of the research causing such a stir.

Among the most widely reported was an observational study of close to 9,000 older male veterans. The authors of this research concluded that testosterone therapy may boost the risk of heart attack, stroke, and death by as much as 30 percent.¹

By itself, that statistic is pretty shocking. But I must point out that these were all men undergoing coronary angiography at a Veterans Affairs hospital. Needless to say, we’re not talking about a healthy study population, here.

In fact, even by modern American standards, the men in this study were quite sick to begin with.

Roughly 20 percent had a history of heart attack. A good half of them had diabetes. And more than 80 percent had coronary artery disease.

What’s more, the testosterone doses used here were almost triple the normal starting dose. So it’s hard to imagine that these findings apply to every patient on T. (And as I’ll explain in a moment, they almost certainly don’t.)

Another damning study appeared in the journal PLoS One at the end of January.² This one found an elevated risk of heart attack in men younger than 65. But only if they had a history of heart disease. (Again, a rather noteworthy distinction.)

Researchers did identify increased risk of heart attack in men over the age of 74, even without a history of heart disease.

Yes, these potential risks are cause for some concern—for some men. But it’s important to look at them in the context of the bigger picture. So allow me to take a moment to provide a little relevant framework.

The jaw-dropping true cost of low testosterone

Let’s look at some real numbers, here. Testosterone deficiency affects an incredible amount of men—as many as 4 to 5 million men in the U.S.³ And as many as half of older type-2 diabetic men suffer from testosterone deficiency, as well.⁴

Even more conservative estimates suggest that low testosterone may be responsible for over one million cases of diabetes.⁵ And as much as $500 billion in health care expenses.⁶

Those are not insignificant numbers. And once you factor mortality risk into the equation, the statistics are even more frightening.

One meta-analysis of a dozen studies showed that for every two-point deficiency in serum testosterone, there was a 35 percent increase in risk of death—and a 25 percent increase in heart-related death, specifically.⁷

That’s quite a big difference, to say the least.

In patients with low testosterone, replacement can cut fat mass and boost insulin sensitivity and blood sugar regulation. It can also optimize lipid profiles—reducing LDL cholesterol and triglyceride levels, while increasing beneficial HDL cholesterol levels.

These are all good things. And guess what? They substantially lower your heart disease risk.

The bottom line: Replace responsibly

So what can we really say about the links between T replacement and heart disease? At this point, anyone looking for any kind of definitive answer on the matter is likely to come up empty handed.

So let me simply tell you what I’ve been telling all my patients since this whole mess started.

Whenever you choose to embark on a health-related journey, there are going to be inherent risks and benefits associated with it. In my many years’ experience with testosterone replacement, as long as a patient is closely monitored, there is no reason for him (or her) not to replace.

The key here is responsible replacement. If you’re currently using testosterone therapy or are interested in doing so, always ensure that your doctor is keeping track of changes to your heart health in addition to your testosterone levels.

These are routine precautions that I take with any patient who sees me. And any doctor who knows what he or she is doing will take them, too.

If you don’t already have one, the American College for Advancement in Medicine (ACAM) is a great resource for locating an experienced holistic practitioner in your area. Simply plug your zip code into their search engine at www.acam.org to find a list of physicians near you.

Sidebar

How much T do you need?

As I said earlier, I test all of my patients’ testosterone levels as a matter of routine. It’s just that important. So don’t be afraid to ask your doctor about this critical level. But remember that the range is broad. There’s normal, and then there’s optimal. (You can probably guess which one you should be aiming for.)

As a rule of thumb, optimal testosterone levels are dependent on age. The younger you are, the higher it should be. Ideal T levels for a 20-year-old man (when testosterone is at its peak) are usually somewhere around 1500 ng/dl. That would drop to 1200 ng/dl at 30, 1000 ng/dl at 40, 800 ng/dl at 50, 700 ng/dl at 60, 600 ng/dl at 70, and so on.

For women, the range is a little less predictable. An optimal testosterone level is one where she feels her best. That could be as low as 20 ng/dl. But in my experience, it’s usually closer to 80 ng/dl.

To achieve these levels, I generally start with 1 mg/gram dosages for women and 100 mg/gram dosages for men. I also use bioidentical compounded testosterone almost exclusively. Actually, all T is bioidentical. It’s just the delivery system that makes up the “patentable” part of the formulation. The difference ultimately boils down to price. If your insurance doesn’t cover testosterone replacement therapy, bioidentical compounded products will be significantly cheaper than commercial brands.

But the most important thing to remember is that testosterone therapy should always be individualized. And since your dosage will depend on your baseline numbers and other clinical factors, you should definitely work with a doctor who knows what he or she is doing.

Sources:

1.. “Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels.” JAMA 2013; 310: 1,829-1,836.

2. “Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men.” PLoS One. 2014; 9(1): e85805.

3. “Prevalence, Diagnosis, and Treatment of Hypogonadism in Primary Care Practice,” Boston University School of Medicine/Sexual Medicine (www.bumc.bu.edu/sexualmedicine), accessed 3/13/14

4. “Prevalence of hypogonadism in males aged at least 45 years: the HIM study.” Int J Clin Pract 2006; 60(7): 762-769

5 “The 20-Year Public Health Impact and Direct Cost of Testosterone Deficiency in U.S. Men.” Journal of Sexual Medicine 2013; 10(2): 562-569

6 ibid.

7. “Clinical review: Endogenous testosterone and mortality in men: a systematic review and meta-analysis.” J Clin Endocrinol Metab. 2011; 96(10): 3,007-3,019.