In both men and women, hormone replacement therapy has become very controversial. In women, concerns include risks of breast cancer, uterine cancer, and blood clots. However, these issues must be balanced with the benefits of improved quality of life and the other health benefits of having “normal” estrogen levels.
In the past, testosterone deficiency was both one of the most over-diagnosed and under-diagnosed conditions in men. Now, with all of the TV, print, and radio ads, every man seems to have “low T.” The problem lies in the fact that the numerous potential symptoms of low testosterone are more likely to have other causes. The two most common are fatigue (who isn’t?) and sexual dysfunction (many causes).
Another controversy involves testosterone replacement and the risk of cardiovascular disease. Here is where it gets interesting. For years, we’ve known that testosterone deficiency is associated with higher cardiovascular risk. This may be related to a decrease in lean body mass and therefore an increase in body fat. No one knows for sure. However, recent studies have suggested an increased risk of cardiovascular events with testosterone replacement. Most likely this latter group includes patients that should not be receiving replacement therapy (such as those with pre-existing cardiovascular disease and those with testosterone levels that are already normal for them).
And that raises another question. What is normal? Two seemingly identical individuals may have a different “normal” level. When faced with a potential symptom of low T, it is often difficult to determine whether this association is causal or coincidental. Also, a truly deficient patient should have a predictable response to therapy.
Never just treat a number (in the absence of true symptoms or other related health risks). First of all, why is the number low? Often, we cannot find a reason, but correcting an underlying cause is always the best answer when possible. Second, testosterone replacement does not “boost” your testosterone. When your body sees testosterone from the outside world, it stops making its own. When stopping therapy, natural production does not always return very readily.
So what is the bottom line? Testosterone plays an important role in cardiovascular health, bone density maintenance, sexual function, and a variety of other health issues. It also carries risks, many of which I did not touch upon. Every man has his own individual needs. Proceed with caution and, as always, follow your doctor’s advice.