Manopause is the cover of Time this week, but the disease seems to be a little problematic. First, you can’t trust test results (see below), so any analysis of testosterone is in the eye of the clinician. Since prescription of testosterone is being done without FDA approval, there’s clearly a lack of studies on long term outcomes.
While clinicians can point to short term positive effects of testosterone in aging men, studies of younger men with similar symptoms do not show a direct relationship between testosterone and those symptoms.
A study on the effects of testosterone on patients with heart disease shows that those taking testosterone were more likely to have more heart problems. According to a more conservative study, “only 2% of 40- to 80-year-old men have (low testosterone). In particular obesity, but also impaired general health, are more common causes of low (testosterone) than chronological age.”
For those of us who lived through the estrogen wars, the sudden interest in testosterone is a fearsome reminder that some doctors do not care about history. If we go back twenty years, every woman could benefit from estrogen. Menopause was the disease, and we had the cure. Estrogen was good for everything, and no woman had to age. My eighty-year-old grandmother started to have her period again, all for the sake of her bones getting stronger.
Then came the Women’s Health Initiative Study, which showed that: “Estrogen plus progestin and estrogen alone decreased risk for fractures but increased risk for stroke, thromboembolic events, gallbladder disease, and urinary incontinence.”
Suddenly every prescribing doctor came to the defense of estrogen. I remember arguing with one ob/gyn who said she was looking forward to going on estrogen despite that silly study. It was flawed. Since then, we’ve seen a drop in breast cancer in direct correspondence to our drop in estrogen prescriptions. But now it’s men, and their perpetual need for testosterone, that has us running for our prescription pads.
Here’s the reality. Testosterone alone doesn’t seem to be that effective. Having seen patient after patient on testosterone, I haven’t heard from them that it changed their lives. These are younger men with low desire and with depression, prescribed testosterone because their levels were low. But it doesn’t seem to change the depression, and they experience no increase in desire.
No FDA approval, no long term studies, and I haven’t seen a beneficial effect. This is one illness that I’m not going to be too sorry to see go the way of estrogen replacement for eighty-year-olds.
Testing for Testosterone
Diagnosing low testosterone by blood is not conclusive. According to a review of the literature, “it is important to confirm low testosterone concentrations in men with an initial testosterone level in the mildly hypogonadal range, because 30% of such men may have a normal testosterone level on repeat measurement; also, 15% of healthy young men may have a testosterone level below the normal range in a 24-h period.” If someone wants to get more technical “Equilibrium dialysis and sulfate precipitation are the gold standard for free testosterone and bioavailable testosterone measurement.” But those aren’t available for routine use. Saliva testing for testosterone “cannot be recommended for general use at this time, since the methodology has not been standardized.” (complete review here)