Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The decision to prescribe testosterone replacement therapy or not

Edward Pullen, MD
Meds
June 29, 2012
Share
Tweet
Share

It seems like every day in the office I see at least one man concerned about testosterone deficiency.  If you look at the symptoms of testosterone deficiency most of us have one or more of these symptoms at least some of the time.  Fatigue, depression, weight gain, lack of energy, reduced sex drive, loss of physical strength, and moodiness are all described as symptoms typical of testosterone deficiency. Making the issue even more difficult it the controversy over whether testosterone levels in the lower third of the range reported as normal is in fact normal, or whether some of these men also have symptoms of testosterone deficiency.

Testosterone deficiency is also felt to be more prevalent in patients with several common medical conditions.  These include diabetes, chronic pain, metabolic syndrome, inflammatory arthritis, COPD, and advanced renal disease.  Most if not all of these problems can cause many of the symptoms also associated with testosterone deficiency.

Making the decision of whether to prescribe testosterone replacement therapy or not more vexing is that we know little about the long term effects of testosterone replacement.  We do know that some men on testosterone replacement therapy develop in increased number of red blood cells called polycythemia.  This can require cessation of testosterone therapy because polycythemia can lead to stroke and other serious complications. We don’t know if long term testosterone therapy is associated with more or less atherosclerotic heart disease, prostate enlargement or cancer.  Really we don’t know much at all about the very long term consequences.

This all is reminiscent of the wings in expert opinion on hormone replacement therapy (HRT) in women for treatment of menopause over the last couple of decades.  Consensus of opinion was to treat all women at menopause with HRT  unless there was a specific reason to avoid therapy to prevent vascular and bone disease until data showed otherwise. Now most experts recommend to try to avoid HRT except for short term treatment of severe menopausal symptoms as evidence of HRT hazards including breast cancer and  cardiovascular disease became documented.

Estimates of the prevalence of testosterone deficiency range from 2.8% to 39% in various population with the higher number being in populations with conditions like diabetes, chronic pain, etc.

In summary we are really left to decide on a case-by-case basis whether to start men on testosterone replacement therapy.  In cases where the testosterone levels are very low and the symptoms are typical I feel pretty good about starting therapy. In cases where testosterone levels are only modestly low or are at the low end of normal but symptoms are present it is much less clear when therapy is indicated.  I often feel like my arm is being twisted by some men desperate for some help with their symptoms, and we have to decide on the risk-benefit balance best for them.

When therapy is indicated the route of administration of testosterone, transdermal testosterone as a gel or patch vs. intramuscular (IM) injection is the next decision.  A big factor in making this decision is the high cost of all the branded transdermal products ($330 per month for Androgel on drugstore.com, others similar) which have the advantage of not requiring IM injections and steadier daily dosing. The much less expensive IM shots with the discomfort and risk of IM administration and the peaks and troughs of testosterone levels are often used to reduce cost of therapy.

I look forward to more research on the long term safety, benefits and risks of testosterone deficiency therapy.  I’m confident there is a lot we don’t know.  I suspect the answers will be slow in coming and surprising whatever they show.  Stay tuned but don’t hold your breath.  This research is not likely to be funded by Big Pharma, and I don’t know of any current long term not-for-profit studies underway.

Edward Pullen is a family physician who blogs at DrPullen.com.

Prev

Sometimes both physicians and patients learn the hard way

June 29, 2012 Kevin 6
…
Next

Obstetric anesthesiologists not only relieve pain, they save lives

June 30, 2012 Kevin 1
…

Tagged as: Endocrinology, Medications, Primary Care

Post navigation

< Previous Post
Sometimes both physicians and patients learn the hard way
Next Post >
Obstetric anesthesiologists not only relieve pain, they save lives

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Edward Pullen, MD

  • a desk with keyboard and ipad with the kevinmd logo

    Mal de debarquement: Vertigo and dizziness after a cruise

    Edward Pullen, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Proton pump inhibitors and B12 deficiency: What to do now

    Edward Pullen, MD
  • a desk with keyboard and ipad with the kevinmd logo

    5 preventive services to do, and 5 to avoid

    Edward Pullen, MD

More in Meds

  • Why retail pharmacies are the future of diverse clinical trials

    Shelli Pavone
  • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

    Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO
  • A world without antidepressants: What could possibly go wrong?

    Tomi Mitchell, MD
  • The truth about GLP-1 medications for weight loss: What every patient should know

    Nisha Kuruvadi, DO
  • The hidden bias in how we treat chronic pain

    Richard A. Lawhern, PhD
  • Biologics are not small molecules: the case for pre-allergy testing in an era of immune-based therapies

    Robert Trent
  • Most Popular

  • Past Week

    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
  • Recent Posts

    • Dedicated hypermobility clinics can transform patient care

      Katharina Schwan, MPH | Conditions
    • It’s time for pain protocols to catch up with the opioid crisis

      Sarah White, APRN | Conditions
    • First impressions happen online—not in your exam room

      Sara Meyer | Social media
    • How locum tenens work helps physicians and APPs reclaim control

      Brian Sutter | Policy
    • The hidden incentives driving frivolous malpractice lawsuits

      Howard Smith, MD | Physician
    • Why what doctors say matters more than you think [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
    • When the diagnosis is personal: What my mother’s Alzheimer’s taught me about healing

      Pearl Jones, MD | Conditions
    • Key strategies for smooth EHR transitions in health care

      Sandra Johnson | Tech
    • Reassessing the impact of CDC’s opioid guidelines on chronic pain care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
  • Recent Posts

    • Dedicated hypermobility clinics can transform patient care

      Katharina Schwan, MPH | Conditions
    • It’s time for pain protocols to catch up with the opioid crisis

      Sarah White, APRN | Conditions
    • First impressions happen online—not in your exam room

      Sara Meyer | Social media
    • How locum tenens work helps physicians and APPs reclaim control

      Brian Sutter | Policy
    • The hidden incentives driving frivolous malpractice lawsuits

      Howard Smith, MD | Physician
    • Why what doctors say matters more than you think [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The decision to prescribe testosterone replacement therapy or not
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...