Nearly half of men over age 45 affected by testosterone deficiency
By Pamela Fayerman - Vancouver Sun
January 18, 2012
Low testosterone levels are a common issue for men over age 45. Symptoms of low testosterone include irritability, reduced sex drive, low energy, decreased muscle mass and strength, decreased concentration, lack of morning erections or less rigid erections, decreased volume of ejaculate, infertility, and, just like women in menopause, hot flashes.
VANCOUVER - Testosterone deficiency affects about 40 per cent of men over the age of 45, but only five per cent of them have been diagnosed and provided with replacement treatment, according to a B.C. Medical Journal article.
Dr. Richard Bebb, a Vancouver endocrinologist who authored the piece, said there are many possible causes of testosterone deficiency besides age, including testicular failure, gland problems, radiation or chemotherapy and congenital diseases.
Symptoms of low testosterone include irritability, reduced sex drive, low energy, decreased muscle mass and strength, decreased concentration, lack of morning erections or less rigid erections, decreased volume of ejaculate, infertility, and, just like women in menopause, hot flashes. Testosterone replacement treatment for those with low levels of the male hormone may improve well-being, sexual function, mood, sex drive, bone density, muscle bulk and strength.
There has been steady, year-over-year growth in testosterone prescriptions across B.C. Five years ago, the volume and value of such medications was about half of what it is now. Such prescriptions were valued at $5.6 million in 2010. Pharmacare, the provincial drug insurance plan, pays for one type of testosterone formulation (injection), but approvals for coverage are given on a case-by-case basis.
Bebb said that testosterone replacement therapy is controversial in some circles. But he maintains it’s a safe and effective treatment that’s been used for nearly seven decades.
“Just because studies have shown that 40 per cent of men after age 45 have low levels [on lab testing] doesn’t mean all guys feel it, and we certainly don’t want everyone going to their doctors asking to get checked,” he said. “Screening men who don’t have clinical symptoms is just not appropriate.”
Unlike women, who have benefited from long-term studies on the safety and effectiveness of hormone therapy, doctors treating male patients with such complaints are still waiting for definitive evidence. In the New England Journal of Medicine last year, a six-month study on men over age 65 who used a testosterone gel showed that there was a higher rate of cardiac problems in the men using the hormone, compared to men on a placebo. But Bebb said the study, which was halted early due to adverse events, doesn’t prove a cause and effect relationship between treatment and heart disease.
“More patients in the treatment arm of the study had hypertension or [high cholesterol], thereby predisposing them to cardiovascular disease and biasing the study outcome,” he said, adding that other studies have shown that low testosterone levels may actually increase risk of death in men with cardiovascular disease.
Some of the confusion and controversy around testosterone treatment could be cleared up with the published results of a U.S. National Institutes of Health study on 800 men aged 65 and older with low levels of the hormone and problems with weakness, fatigue and sexual performance. It is also evaluating the hormone’s effects on the heart.
“In the interim, a significantly [testosterone deficient] man who has heart disease or is at risk for heart disease should not be refused therapy on the basis of cardiovascular risk,” Bebb says.
One of the more controversial aspects of testosterone treatment is whether it should be given to men with prostate cancer or if it may increase the risk of developing such cancer. Dr. Larry Goldenberg, a Vancouver urologist and one of Canada’s leading experts on prostate cancer, says there’s no proof that testosterone supplementation increases prostate cancer risk or is dangerous to use in patients with symptoms of low testosterone levels and a history of successfully treated prostate cancer.
Bebb takes a cautionary approach and says until the issue is resolved through well-designed, big studies, treatment can be considered for cancer survivors a year or two after treatment ends, but patients must be closely monitored and should understand the possible risks.
Bebb points out that misuse of testosterone by athletes is common. Men who take unusually high doses of testosterone can be spotted by their smaller testicles, low sperm counts, elevated liver function test results, and several other abnormal blood tests.
Male menopause is sometimes called andropause but it is properly called hypogonadism by doctors. After the age of 30, testosterone levels decrease about 1.5 per cent a year but may not cause troubling symptoms of deficiency. The physical manifestations of low testosterone can include body fat around the middle, breast fat, smaller testicles, height loss and bone fractures.
Unlike women, who experience an abrupt decline in estrogen levels at the time of menopause, males encounter a more gradual decline and their symptoms are often viewed as a normal part of aging, rather than as a hormonal deficiency. But Bebb said men with symptoms should be offered blood tests to determine their levels. Testosterone levels fluctuate so testing should always be done before 10 a.m. since they may fall naturally in the afternoon.
Sun Health Issues Reporter
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