{"id":548,"date":"2015-01-24T11:00:42","date_gmt":"2015-01-24T11:00:42","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=548"},"modified":"2017-08-21T12:00:34","modified_gmt":"2017-08-21T12:00:34","slug":"primary-care-corner-with-geoffrey-modest-md-testosterone-again","status":"publish","type":"post","link":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/01\/24\/primary-care-corner-with-geoffrey-modest-md-testosterone-again\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Testosterone, again"},"content":{"rendered":"

By: Dr. Geoffrey Modest\u00a0<\/strong><\/p>\n

\n

There have been a couple of articles on testosterone:<\/p>\n

1. Article in j clin endocrinology and metabolism on testosterone therapy for men with type\u00a02 diabetes (T2D)\u00a0and low testosterone levels (see\u00a0doi: 10.1210\/jc.2014-1872<\/strong>). 88 men aged 35-70 (ave age 62) with A1c\u00a0<8.5%, total testosterone (TT)\u00a0< 346 ng\/dl (they specifically were looking for men with low normal testosterone levels, and excluded those with TT < 144),\u00a0with mild to moderate \u201caging male symptoms” and erectile dysfunction, randomized to 40 weeks of IM testosterone undecanoate 1000\u00a0mg\u00a0or placebo, assessing their AMS (aging male symptoms score, a validated\u00a017-item scale to assess 3 domains: somatovegetative, psychological, and sexual), as well as\u00a0sexual desire and erectile function. This analysis was a secondary one; with the primary study finding in these men that testosterone injections did not lead to any change in glucose metabolism (insulin resistance or glycemic control) or visceral adiposity (for that study see:\u00a0Diabetes Care 2014;37:2098\u20132107).\u00a0Results of current analysis:<\/p>\n

–Testosterone injections did in fact increase TT levels<\/p>\n

–No difference in the AMS score with testosterone injections<\/p>\n

–No difference in sexual desire\u00a0(interestingly, those on IM testosterone actually had reduced erectile function)<\/p>\n

–Although the utility of free testosterone levels is debated, they found that 72% of the men had low free testosterone and there was no difference in results for them vs.. those with low TT<\/p>\n

–Symptoms overall were worse at baseline if men were depressed or if had\u00a0micro vascular complications (neither of\u00a0these correlated with TT levels)<\/p>\n

–The authors are careful to note that their conclusions do not apply to symptomatic men with unequivocally low testosterone levels, and that their results for men with less severe androgen deficiency were somewhat at odds with some other studies<\/p>\n

Note: 30-50% of aging, obese men with T2D have low TT, though\u00a0the vast majority has only mildly decreased TT (as in this study). In observational studies, 55-70% of those with low TT levels\u00a0have symptoms of androgen deficiency, but 50-55% of those with normal TT had similar symptoms. So, I think this study is relevant to us\u00a0because it highlights the importance (and high prevalence) of depression as a likely cause of sexual dysfunction, and the lack of significant efficacy of testosterone therapy. The data for clinical benefit of\u00a0testosterone therapy in older men is very mixed, with best data\u00a0for improving libido, though no significant change in erectile function or sexual satisfaction. As a result,\u00a0the Institute of Medicine’s committee on testosterone concluded that there is insufficient evidence to\u00a0recommend that testosterone treatment of older men have any well-established benefit. The number of testosterone prescriptions has increased dramatically in the last several years\u00a0— this study\u00a0reinforces the lack of real utility for testosterone replacement therapy for the majority of men (with the exception of those with profound TT\u00a0deficiency, eg a man with symptoms consistent with testosterone deficiency —\u00a0eg decreased libido, mood, osteoporosis, energy plus a TT level measured between8-10AM\u00a0and less than 300 ng\/dL, and\u00a0this test\u00a0should be repeated\/confirmed\u00a02x more before giving meds\u00a0since there are significant daily variations in TT). And there are real risks to testosterone therapy.<\/p>\n

\n

2. The Endocrine Society came out with a clinical practice guideline for androgen therapy in women (see\u00a0doi: 10.1210\/jc.2014-2260<\/strong>). They basically recommend:<\/p>\n

–Do\u00a0not diagnose androgen deficiency in healthy women because of lack of well-defined syndrome and lack of data correlating symptoms with androgen levels. And don’t use testosterone routinely in those with hypopituitarism, adrenal insufficiency, etc.<\/p>\n

–Do\u00a0not use testosterone therapy for infertility; sexual dysfunction (other than “hypoactive sexual desire syndrome”, which studies suggest may respond to short term testosterone therapy, though endogenous testosterone levels do not predict response to therapy even in this “syndrome”); cognitive, cardiovascular, metabolic, or bone health; or general well-being<\/p>\n

–Not use dehydroepiandrosterone\u200b<\/p>\n

–AND, none of these testosterone preparations are available in the US for women, women frequently develop very high serum testosterone levels on therapy, and\u00a0long-term safety data are lacking (though it seems that the testosterone equivalent doses for women is about 10% of those used in men).<\/p>\n

\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

Testosterone, again […]<\/p>\n

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