Testosterone
Elizabeth Briand
Promises of restored youth and vigor have long roused the imagination, from the golden apples of Greek myth to Juan Ponce de Leon’s search for the Fountain of Youth in Florida. In recent years, testosterone has been touted online and in social media as another cure-all, a way to turn back the clock and slow the inevitable effects of aging.
Research, however, does not bear this out. What it has shown is that exogenous testosterone is a powerful and effective way to combat testosterone deficiency or hypogonadism, a condition that causes lower-than-normal testosterone levels.
“There is no controversy about that—testosterone is a bona fide and legitimate treatment for testosterone deficiency,” said Shalender Bhasin, MD, an endocrinologist with Brigham and Women’s Hospital’s Division of Endocrinology, Diabetes and Hypertension.
“Where things get more complicated is when people start to conflate it with age-related conditions and are using testosterone for aging,” he said. “Testosterone is not approved for aging or age-related conditions, but testosterone is approved for hypogonadism whether people are young or old.”
Testosterone levels decline naturally as men age, and other conditions such as obesity and diabetes or the effects of prostate cancer treatment can also affect the hormone’s production. Men may experience a wide range of symptoms as a result of hypogonadism, including a reduction in sexual desire and difficulty with erections.
In addition, in older men, fatigue is a common symptom while severe deficiencies can cause hot flashes. Low mood is another symptom, as half of men experiencing testosterone deficiency will have some depressive symptoms or loss of joy.
Experts note that it is important to fully investigate the causes of these symptoms before seeking testosterone replacement.
“Some of these symptoms, especially fatigue, can be a manifestation of many other chronic diseases,” said Bhasin. “People with heart failure or cancer may report the same symptoms. That’s why it’s really important to do a proper work up to determine if the symptoms are due to testosterone deficiency or some other condition, such as cancer, heart failure, or chronic obstructive lung disease.”
Safety and effectiveness
If an individual is found to have testosterone deficiency, the good news is that a number of studies have demonstrated the effectiveness of testosterone replacement therapy, including the Testosterone (or T) Trials in 2016, which included nearly 800 men with testosterone deficiency and examined sexual function, physical function, and vitality.
Overall, studies have shown that the most consistent and well-established benefits of testosterone replacement therapy are in “improving sexual function, sexual desire, overall sexual activity and satisfaction with sexual experience,” Bhasin said. “The overall effects on erectile dysfunction have been more variable and relatively small.”
The 2023 TRAVERSE trial, which Bhasin coauthored, examined the cardiovascular safety of testosterone replacement therapy in middle-aged and older men with hypogonadism and a preexisting or high risk of CVD.
“There was no difference in the number of heart attacks, strokes, or deaths due to cardiovascular causes,” said Bhasin. “That was very reassuring—that it did not increase cardiovascular events.”
The research team also found that another area that had elicited concern in the past—testosterone’s role in prostate cancer—was not a significant issue.
“The overall incidence of prostate cancer events was very low, and most of these were low-grade cancers,” he said, noting, however, that the TRAVERSE study’s participants had been carefully selected to not be at high risk for prostate cancer, as its main focus was on cardiovascular health.
The study also found an increased rate of bone fractures in older patients, which Bhasin called paradoxical because testosterone is known to increase bone strength. Researchers believe that patients became more physically active after therapy, leading to more falls and injuries.
Seeking the right care from the right source
Overall, for older men suffering from testosterone deficiency, the benefits of replacement therapy can be substantial.
“People talk a lot about overuse of testosterone, but testosterone deficiency is both underdiagnosed and over-diagnosed,” said Bhasin. “The key thing is that, like any other condition, it needs to be properly evaluated.”
He added, “We don’t treat old age with testosterone. We treat testosterone deficiency, and that’s legitimate, and it can be done safely and in a very rigorous manner.” ■