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Testosterone replacement, truths and myths

March 16th, 2018

By Lt. Cmdr. Guillermo Patino, department head, Urology, Naval Hospital Pensacola
I recently had a patient tell me that he was receiving testosterone replacement therapy from a physician in the community because his physician at NHP would not replace it.
As I looked at his labs, I noted that he had not been started on testosterone replacement because his testosterone level was almost twice what is considered a normal value. When I inquired about the credentials of the physician that was providing him with this therapy, my patient stated that it was a civilian doctor who was a gynecologist by training, but who happened to do “testosterone replacement as a business on the side.”
I was shocked to hear of such a practice and could not comprehend how anyone could go along with this ill advised plan. Not a week had passed from this exchange when I was called by a good friend who had questions about testosterone replacement because he had seen a civilian Emergency Medicine physician who had started him on testosterone replacement and you guessed it, it was his “business on the side.”
I still find it hard to believe that such dubious practices exist, but I get it, testosterone replacement is a hot item at the moment. Men want to be faster, live longer and regain the vitality that they once enjoyed in their youth. Television commercials and infomercials are constant reminders that testosterone replacement may, in fact, be the mythical Fountain of Youth that has famously eluded even the most daring explorers.
Nonetheless, testosterone replacement should be approached with trepidation, particularly when the person telling you that you will benefit from it is a person who offers you this therapy outside of his scope of practice. Gynecologists and emergency room physicians are not trained in the management of men with low testosterone and in fact, there are many urologists who themselves are leery of providing this type of therapy to patients because the truth is that there is much that is unknown about the appropriateness of testosterone replacement in certain age groups, particularly men of normal sexual and reproductive function.
Virtually all large randomized controlled trials looking to establish a “normal” testosterone value were conducted in men who were well into their 60s and it remains unclear as to how reliable these studies were in setting the benchmark for all testosterone replacement. Testosterone fluctuates greatly in men, it binds to several proteins within our serum and thus the portion of testosterone that is available to exert its end-organ effects will vary based on age, body mass index (BMI) and the time of day the blood is tested. In addition, numerous clinical conditions exist that can alter your testosterone values including type two diabetes, thyroid disorders and alcohol consumption to name a few.
Another important variable, and in my opinion, one that is of great concern is that there are many lab assays available to evaluate your testosterone level. This means that if you go to five different labs, you may very well get five different results. This lack of standardization is actually fairly commonplace in clinical laboratories, but it can certainly make the management of hypogonadal (low testosterone) men difficult.
If this is not enough to confuse you, then you should also know that the symptoms of low testosterone are very common in men with other disorders such as depression, liver disease, anxiety and hypothyroidism. With all this being said, it might not surprise you to know that there is no universally accepted threshold for determining when a man has low testosterone. Practically speaking, it is important to recognize that lab values can be abnormally low for very good reasons and that not all men who have symptoms of low testosterone should have testosterone replacement therapy.
You might ask yourself what the harm is in replacing something that is naturally occurring in the body, but testosterone replacement is not a benign therapy. Some common side effects include fluid retention, worsening of sleep apnea and acne. Testosterone replacement can have significant consequences in men with undiagnosed prostate cancer in whom the cancer can grow and become more clinically relevant than it had been. In young fertile men, decreased sperm count and permanent infertility can occur. Cholesterol can increase and breast enlargement can also ensue. Some of these side effects are not that uncommon and require close monitoring during the course of therapy.
I often tell my patients that they need to be good consumers of their health care, ask their doctor questions and educate themselves about their medical conditions. While many men are likely to benefit from testosterone replacement therapy, the diagnosis of low testosterone is not an easy one to make and that the clinical decision to start therapy needs to be made in conjunction with a clinician who is aware of the many pitfalls involved in the management of hypogonadal men.
Editor’s Note: Beneficiaries of NHP should speak to their provider or Medical Home Port Team if they have questions about testosterone replacement therapy.

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