By Ken Cohen, M.D., F.A.C.P.
Chief Medical Officer
As men age, starting in their 30s or 40s, testosterone levels naturally decline. Television and radio commercials tout the rejuvenating effects of testosterone in older men with low testosterone or “low T.” While there may be some benefit from testosterone treatment in certain older men, testosterone is not a rejuvenating therapy.
A low testosterone level by itself does not need treatment. Only men with symptoms of low testosterone and blood levels that confirm this as the cause of the symptoms should consider testosterone therapy. The decision to start testosterone treatment should only be made after a discussion with your health care provider about the risks and possible benefits of treatment.
Symptoms of low testosterone include low sex drive, erectile dysfunction, fatigue, decreased muscle mass and strength, changes in mood, and difficulty concentrating. Keep in mind that in addition to low testosterone, other medical conditions and certain medications can cause these symptoms.
Testosterone replacement therapy can have side effects and the long-term risks and benefits are not well known. However, recent results from several testosterone trials designed by the National Institutes of Health (NIH) to answer questions about testosterone treatment in older men are beginning to give us a clearer picture about the short-term benefits and risks of testosterone replacement treatment. This research looked at 12 months of testosterone replacement treatment in men over 65 with low testosterone levels and focused on issues such as sexual function, vitality (depression and/or fatigue), cognitive function, bone density, and cardiovascular effects.
Sexual Function – Both sexual desire and erectile function improved to a small extent with testosterone treatment but the benefits began to decrease after several months of treatment. The increase in erectile function was less than is produced with erectile dysfunction (ED) drugs such as Viagra, Cialis, and Levitra.
Vitality– A small improvement in mood and fatigue was reported with testosterone treatment.
Cognitive Function– Testosterone treatment did not improve cognitive function or memory.
Bone Density– While testosterone treatment improved bone density in the spine and hip the effect on the risk of experiencing an osteoporosis related bone fracture is not known.
Cardiovascular risk– There was an increase in arterial plaque, which is associated with heart disease, in individuals treated with testosterone but this trial was unable to conclude whether this caused an increased risk of heart attack or stroke. Larger and longer trials will be needed to determine whether testosterone replacement therapy increases the risk of heart attack or stroke in older men. These studies are underway but it will be several years before results become available.
So what does all this mean for an older man considering testosterone treatment? There appears to be small to modest benefits of testosterone therapy for several symptoms of low testosterone while the long-term risks of treatment continue to be unknown. However, keep in mind that there is a wide range of responses to testosterone treatment with some men benefiting little and others receiving more benefit. If the decision is made to start testosterone treatment regular follow up with a health care provider is important to ensure the treatment is providing the desired benefit, and also to monitor for potential toxicity such as excessive elevation of the red blood cell count or the development of sleep apnea.
If older men with symptoms of low testosterone decide to start testosterone treatment they must then select a testosterone product in consultation with their health care provider. Factors to consider when selecting a testosterone product include cost and convenience. Depo-testosterone is an injection that is typically given every two weeks. This is the least costly form of testosterone, costing a fraction of that of other forms of testosterone. Testosterone is also available as gels and patches that are absorbed through the skin but are significantly more expensive and require daily application.
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