Low testosterone is usually not the underlying problem but rather a symptom of the underlying problem.
In recent years, prescriptions for testosterone in the US have skyrocketed. There are now “Low T” clinics popping up in suburban strip malls across the country, and you can even find treatment online! Prescription testosterone fuels a business which brings in over $2 Billion a year, yet there is debate over the appropriateness of the therapy.
Without a doubt, there are cases of low testosterone (termed “hypogonadism”) for which testosterone replacement is crucial. The ability to replace this hormone through medication is another example of the miracles offered by modern medicine and science. Yet, this could be said of any medical condition and its associated treatment. You don’t see strip mall clinics set up to manage conditions like high blood pressure or psoriasis. Why testosterone?
There is no definite, agreed-upon definition of hypogonadism in medical literature. Most studies use some combination of testosterone levels in the blood, along with the presence of multiple symptoms. As there is no consensus for diagnosis, and since treatment is a multi-billion dollar cash business, you can imagine there might be some room for…shall we say, “bias”.
In addition to this lack of agreement on diagnostic criteria, a major problem that pervades this Low T industry is a disinterest in diagnosing or treating an underlying cause for low testosterone. Many doctors are happy to simply prescribe enough hormone to take a patient from “low” (or even “low-normal”) to the upper reaches of “normal”, or even higher. This is an easy fix for both the doctor and the patient, and often the patient is unaware of the alternatives or the risks of treatment. While the underlying problem is addressed, sometimes a short course of hormone replacement is all that is needed. The patient and their symptoms are rarely addressed in this manner, often being treated for years, or even indefinitely
As time goes by, the patient may require greater amounts of hormone to keep testosterone numbers elevated. In fact, symptoms are often not alleviated with a raise in testosterone levels, so sometimes a doctor will just prescribe more, despite normalized levels. Many doctors have simply stopped looking for a reason for the low levels in the first place.
The human body is comprised of a complex interplay of systems, and hormonal systems are perhaps the most complicated. It is exceedingly rare that an isolated hormone will just take a nosedive for no underlying reason. Yet some doctors see a low testosterone level and just throw more hormone in the mix. In medical school, we’re all told, “Don’t treat the number, treat the patient.” It seems there are many who have lost sight of this.
The cause(s) of low testosterone can very often be treated, allowing the body’s own hormonal system to return to normal. There are many variables that may decrease testosterone production. Low testosterone is usually not the underlying problem but rather a symptom of the underlying problem.
If a patient presents with chest pain, we don’t just give them enough pain medicine to make them feel better. We quickly look at why they are having pain. When they present with anemia, we don’t just transfuse them with blood and send them home. No, we look for the reason behind their low blood counts. Why should we treat low testosterone differently?
There are many things that can lead to abnormally low hormone levels including excess body fat, sugar consumption, stress, overtraining or lack of proper recovery, poor sleep, sleep apnea, lack of exercise…and the list goes on. In some conditions, testosterone treatment might actually make the problem worse!
If you are an endurance athlete, it is very likely that your total testosterone levels are on the lower end of normal. This is common, even expected. I work with recreational and professional endurance athletes who, at the top of their game and with no symptoms of hypogonadism, have testosterone levels in this low-normal range. It is not pathologic. It’s an expected response to extended endurance training. There is absolutely no reason to treat these athletes with testosterone replacement. Notably though, we do follow levels of total testosterone, free testosterone, and cortisol to evaluate response to training regimens. In those scenarios when testosterone drops, an adjustment in training load and recovery will rectify the problem.
Adding exogenous hormone can disrupt the balance of other hormones and impact the body’s ability to produce its own testosterone in the future. It also can lead to an overproduction of red blood cells, making the blood “thick”. This can result in blood clots, heart attacks, and strokes. The medical literature establishing the safety of liberal hormone replacement is woefully lacking, but these adverse events are becoming more recognized. In fact, it’s come up on numerous occasions as I converse with doctors at the hospital during my ER shifts. While this is only my opinion and conjecture, I fully expect that we will start to see these treatments lose favor and very likely be subject to class-action suits against manufacturers and Low T clinics in the coming years.
To be clear, I am not placing any blame on patients. There is a vast marketing machine behind the proliferation of Low T treatment. When someone is experiencing concerning symptoms and a doctor offers what seems like a reasonable diagnosis and a simple fix, patients are going to take it! As doctors, the responsibility rests on us to determine when treatment is appropriate and when it is merely a symptomatic cover-up of a true underlying problem. I think we as doctors are failing in this regard - too many quick fixes prescribed to well-meaning patients.
Next week I’ll talk about the implication of testosterone treatment for recreational athletes and their responsibility under the World Anti-Doping (WADA) code.