Tuesday, February 17, 2015

Debating testosterone screening and therapy in older men

- Kenny Lin, MD, MPH

A good number of new patients to my practice are older men whose previous physicians have retired. More and more often, I've noticed while reviewing records from previous physicals that they have had their testosterone levels checked - usually without any documented rationale for doing so. In two Pro-Con editorials in the February 15th issue of American Family Physician, Drs. Joel Heidelbaugh and Adriane Fugh-Berman debate the merits and potential unintended consequences of screening for testosterone deficiency in older men. Dr. Heidelbaugh points out that observational studies have associated low serum testosterone levels with cardiovascular disease, cancer, impaired glucose tolerance, and metabolic syndrome. He further argues that symptoms of testosterone deficiency may be erroneously attributed to normal aging:

Although screening targets asymptomatic men, testosterone deficiency is unique because symptoms are not always well defined. This warrants casting a wider net to identify a treatable condition. Symptoms such as depression, fatigue, and inability to perform vigorous activity are related to low testosterone levels, whereas there is an inverse relationship between the number of sexual symptoms and testosterone levels.

On the other hand, Dr. Fugh-Berman raises concerns about overly aggressive marketing of testosterone supplements by pharmaceutical companies, such as online symptom surveys that seem designed to elicit "yes" answers from most older men.

These questions demonstrate how pharmaceutical companies use nonspecific symptoms to foster disease states and then convince physicians that these conditions are real. In this case, the disease state is marketed to consumers as Low T, and to physicians as late-onset hypogonadism.

Of observed associations between low testosterone levels and chronic diseases, Dr. Fugh-Berman counters that "association does not prove causation, and there is no reliable evidence that testosterone treatment improves any chronic disease."

Last September, an advisory committee to the U.S. Food and Drug Administration considered the potential cardiovascular risks for testosterone therapy and voted to exclude men with age-related testosterone declines from indications for testosterone use and to support performing additional studies to clarify cardiovascular harms. Whether clinical practice will evolve to reflect a similar level of caution is unclear. A 2013 analysis of a health insurance database showed that 25% of men prescribed a testosterone supplement never had a testosterone level checked, while other men with apparently normal levels nonetheless received therapy. At a minimum, family physicians who prescribe testosterone supplements should heed the Choosing Wisely recommendation to avoid these unsupported practices.