Testosterone deficiency in men: Is testosterone treatment the best answer?

Amanda Lyons

7/08/2018 3:07:12 PM

Endocrinologist Professor Mathis Grossmann explores why prescribing testosterone is not always the best approach in older men with low levels.

Endocrinologist Professor Mathis Grossmann believes testosterone treatment is not necessary for treatment of low testosterone in older men.
Endocrinologist Professor Mathis Grossmann believes testosterone treatment is not necessary for treatment of low testosterone in older men.

Low testosterone levels can have debilitating results for men.
‘In young males it can [lead to] low sperm counts, depression, reduced physical and mental strength, and a sense of embarrassment of inadequacy due to impotence and infertility,’ Dr Peter Strickland, a GP with an interest in men’s health, told newsGP.
‘In older males it is [marked by] a loss of libido and impotency, affecting both themselves and their partners.’
Testosterone deficiency can have quite different causes depending on the age of the man affected.
‘In younger males the causes are more complex and related to damage of the testes from certain drugs, such as anti-cancer drugs, or having to have one or both testes removed due to cancer or accident, and external radiation damage from radiotherapy in the pelvic region as part of oncology management,’ Dr Strickland said. 
‘Deficiency in older males is simply [due to] ageing of the body in general and supply of circulation to both testes, or secondary to anti-testosterone drugs for treatment of prostate cancer.’
Treatment of all types of testosterone deficiency with prescribing used to be common, and Australian patients could access prescriptions through their GP. However, in 2015 the Pharmaceutical Benefits Schedule (PBS) tightened its criteria for testosterone prescribing, instead requiring that GPs consult with a relevant specialist or registered member of the Australasian Chapter of Sexual Health Medicine before they can prescribe the treatment.
The PBS decision was underpinned by emerging evidence regarding the use of testosterone treatment, particularly in relation to older men.
‘The benefits were [shown to be] quite modest, and the long-term risks are simply not known,’ Professor Mathis Grossmann, endocrinologist and Professor of Medicine at the University of Melbourne, Austin Health, told newsGP.
‘There is controversy about prostate cancer risk, which is probably low, but there are unresolved issues regarding cardiovascular risk, with some studies suggesting the benefit of testosterone treatment and other studies suggesting harm.’
According to Professor Grossmann, when assessing a patient for testosterone deficiency, it is vital to identify whether a patient is experiencing organic hypogonadism, which is caused by a clear pathology and for which testosterone treatment is often appropriate, or instead what is often referred to as ‘late-onset hypogonadism’.
‘That is the situation where an older man, often with comorbidities such as diabetes and obesity, presents with modestly low testosterone, so testosterone levels are not generally as low as they would be in organic hypogonadism,’ he explained.
Professor Grossmann believes that testosterone therapy is generally not warranted for these particular cases.
‘The question is, is the lower testosterone causing the symptoms, or is it the obesity or the diabetes, that causes the low testosterone?’ he said.
‘We think that, in general, it is more likely that testosterone is simply a marker of poor health in the latter scenario.’
The changes in recommended treatment of older men with testosterone deficiency mean it is usually better to approach the condition with lifestyle changes and preventive measures than prescribing, bringing it even further into the wheelhouse of general practice.
‘With older men who come with non-specific symptoms like tiredness, and [symptoms like] erectile dysfunction … testosterone treatment as a general rule is not the answer; optimisation of comorbidities and treating the presenting complaint, such as phosphodiesterase inhibitors for erectile dysfunction, is more important,’ Professor Grossmann said.
‘While it is true that testosterone decreases modestly with ageing, it is probably more related to the accumulation of aged-related comorbidities. And there’s some Australian evidence that if you’re a very healthy older man, your testosterone levels may not drop at all.
‘In that context, and the recent PBS guidelines really reflect that, the emphasis on treatment should be more on trying to optimise the comorbidities and trying to get people to lose weight, rather than giving testosterone treatment. There’s good data that if you lose weight, your testosterone goes up and you feel better.
‘So that is the big picture.’
GPs looking for further information can access the Endocrine Society of Australia position statements, published in the Medical Journal of Australia, or visit the Endocrine Society of Australia website.
Meanwhile, there is further evidence being gathered on the issue right here in Australia through a study that is assessing whether testosterone treatment combined with lifestyle change can prevent type 2 diabetes in men who have pre-diabetes and low testosterone.
‘It is called ‘T4DM’, T for testosterone, DM for diabetes mellitus,’ Professor Grossmann said.
‘The trial will finish follow-up by about mid-2019, and then it will be the largest testosterone trial ever conducted on older men.’

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Gregory   9/08/2018 7:38:45 PM

Thanks for useful information!