Tuesday, March 4, 2014

Too much testosterone therapy?

- Kenny Lin, MD, MPH

If the ubiquitous television advertisements are to be believed, there is an epidemic of low testosterone (or “low T” for short) sweeping America. Men of all ages have been instructed in these advertisements to “ask their doctor” if they have any one of a list of nonspecific symptoms that could be improved with testosterone therapy. (Future AFP editorials will address the controversy about widespread testing for low testosterone levels.) Although hypogonadism is the only widely recognized indication for testosterone supplementation, recent research suggests that substantial numbers of men without testosterone deficiency are receiving prescriptions.

Concerns about excessive testosterone therapy led the Endocrine Society and the American Urological Association to recommend in the Choosing Wisely campaign that clinicians not prescribe it to men without biochemical evidence of testosterone deficiency, including men with erectile dysfunction and normal testosterone levels. In addition to having questionable benefits for these patients, supplementation is potentially harmful. Recent studies have linked testosterone therapy to an increased risk of cardiovascular events in men over age 65 and in younger men with heart disease.

The Endocrine Society recently recommended that physicians talk with patients about these potential risks and avoid prescribing testosterone to men without hypogonadism. In the meantime, the U.S. Food and Drug Administration is re-evaluating the risk of stroke, heart attack, and death associated with testosterone products. Given well-documented efforts of pharmaceutical companies to expand the market for testosterone therapy by ghostwriting articles for lay and scientific publications, family physicians would be wise to steer clear of commercially-sponsored educational offerings (disclosure of conflicts of interest is not enough) and restrict prescriptions of testosterone to patients with FDA-approved indications.

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