Testosterone Replacement (1 of 2)
Across the US, hormone replacement therapy is becoming more popular every year. Recreational athletes are no exception to this trend, and this is perhaps most prevalent among the “weekend-warrior” masters athlete crowd. But just because it is a common theme in treatment, does that mean it’s good medicine?
I’m going to post a two-part series of articles examining hormone replacement therapies and their use in athletes. Without a doubt, there are clinical conditions which require this treatment. There are a growing number of patients, however, who are being treated without meeting accepted diagnostic criteria. This could be the evolution of medical care, working to aggressively treat previously unrecognized conditions. Or it could be a bandwagon on which patients and doctors are hitching their hopes, exchanging large amounts of money, yet missing the underlying problem.
Additionally, since this series is specifically aimed at an active patient population, I will discuss the implications of these treatment protocols when it comes to competition. Athletes who register for an event sanctioned by a national federation often agree to abide by the code of the World Anti-Doping Agency (WADA). If you are running your local 5K or marathon, you likely agreed to this code (and to be tested!). If you sign up for the local sprint triathlon or cycling crit, the same thing applies. Far too often, I see athletes in my office who have been placed on treatments which technically amount to doping! I don’t believe they have any intent or awareness that they are breaking the rules, and many are stunned to find this out. My goal in discussing this is not to point fingers! Rather, it is to inform athletes at all levels that there are expectations and rules to which they have agreed and can be publicly punished for breaking. And often times, there is a safer and healthier way to address their symptoms.
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. You can even get treated online! Prescription testosterone fuels a business which brings in over $2 Billion per 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. But this could be said of any medical condition and its associated treatment. You don’t see strip mall clinics set up to manage singular 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 with treatment being 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. Other treatments can fix the underlying problem, and sometimes a short course of hormone replacement may be all that is needed while that underlying issue is addressed. Rarely though is that how the patient and their symptoms are addressed.
As time goes by, the patient may require greater amounts of hormone to keep their testosterone numbers elevated. In fact, symptoms are often not alleviated with a rise in testosterone levels, so sometimes a doctor will just prescribe more, despite normalized levels. What ever happened to looking for a reason for 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 are proponents of seeing a low testosterone level and just throwing 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 doctors 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 things that 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 on their way. 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: excess body fat, sugar consumption, stress, overtraining or lack of proper recovery in athletes, 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 a diagnosis and a simple fix, of course they 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 coverup of a true underlying problem. I think we are failing in this regard. Too many quick fixes are being passed out to well-meaning patients.
In the next post I’ll talk about the implication of testosterone treatment for recreational athletes and their responsibility under the World Anti-Doping (WADA) code.