Coming Soon: Decade of Testosterone

In abundance, the male sex hormone testosterone has become synonymous with virility, authority, and bulging pectorals. And in short supply, it is understood to result in sexual apathy and erectile dysfunction. What most men are unaware of, however, is the more dangerous link between low testosterone and early death from heart attack, vascular disease, and complications from diabetes.

Normal testosterone levels are essential to men’s well-being, in and out of the bedroom, says Abdulmaged Traish (GRS’78, GSM’94), a School of Medicine professor of biochemistry and urology and director of the Laboratory for Sexual Medicine Research. A coauthor of a recent study implicating testosterone deficiency in cardiovascular disease, Traish, winner of the 2006 Metcalf Cup and Prize, the University’s highest teaching honor, is on a mission to educate primary care doctors about the prevalence and the dangers of low testosterone.

Known as androgen deficiency, or AD, low testosterone is a treatable condition believed to affect nearly a third of men between 35 and 60. In the study, published in the September-October issue of the Journal of Andrology, Traish and his colleagues evaluated 29 years of data on the link between AD and cardiovascular risk factors, ranging from cholesterol levels to blood pressure. The authors found that the higher the testosterone levels of men, the lower the risk of death from cardiovascular disease, and they concluded that replacing testosterone (T therapy) in men with AD could reduce their risk of heart attack and prolong lives.

Traish says many physicians are reluctant to diagnose and treat AD because of a long suspected, but now debunked, link between testosterone and prostate cancer.

And he is determined to correct the situation. One of a contingent of urologists and endocrinologists sounding the AD battle cry, Traish says that 2010 will herald “the decade of testosterone.”

For pharmaceutical companies, testosterone’s decade is well under way. According to Business Week, sales of testosterone products already on the market soared 25 percent in the 12 months ending June 2009, to just under $1 billion. Sales of the ubiquitous Viagra declined during this period.

Indicated by a simple, inexpensive blood test, androgen deficiency is defined by the Food and Drug Administration as a testosterone level of 300 nanograms per deciliter of blood or lower, with the normal range 300 to 1,200. Because hormone levels vary over the course of the day, Traish recommends that men be tested in the morning, when testosterone is highest. Most family doctors don’t order the test, but they should, he says, as a matter of course.

“We want primary care doctors, the gatekeepers, to be aware of AD,” he says. “It’s not just a quality of life issue; it’s a question of mortality.”

Testosterone is important for skeletal and muscular health as well as healthy blood vessels and red blood cells. As they adjust their belts, men over 35 might shrug off burgeoning guts as an unfortunate but inevitable sign of aging. “But now we’ve learned that this new fat is an organ of its own,” Traish says. “It causes a lot of bad things to happen.”

In fact, he says, AD can almost always be diagnosed without a blood test, even without visiting the doctor. The best evidence is waking up without an erection.

“It’s the first thing I ask patients,” he says. “After T therapy, the answer is always yes.”

When testosterone is prescribed, Traish says, it is not in the doses associated with illicit doping in athletes. And while testosterone does increases muscle mass and does fuel sex drive, no one should fear a pandemic of testosterone-pumped predators.

“We just want to bring the levels up to what they should be normally,” he says. Unlike the female sex hormone estrogen, which drops radically at menopause, testosterone decreases slowly and gradually after men reach 35. Factors that can speed its decline are stress, anxiety, obesity, genetics, and prostate cancer treatments involving surgery or drug therapies based on some doctors’ belief that testosterone deprivation stops early prostate cancers from growing.

Men can increase their testosterone levels through exercise, a healthful diet, and avoiding stress. But when androgen-deficient men are given testosterone, Traish says, their fat goes down, their overall muscle mass goes up, their bad cholesterol goes down, and their good cholesterol goes up.

He says that study after study show the protective health benefits of T therapy. “One study compared a group of male type II diabetics who made lifestyle changes alone with men who were taking better care of themselves but also given testosterone,” says Traish. “This is very exciting. In the testosterone group, the diabetes was completely reversed.”

Testosterone can be administered in a variety of ways. The least effective is a pill, because the liver breaks the hormone down quickly and much of it escapes in urine. Other options are an injection, a gel, a patch, and slow-release pellets inserted into a small cut in the patient’s buttocks.

Each has its drawbacks. The gel can be transferred from skin to skin. “You don’t want to use it if you’ll be holding a baby,” says Traish. Many men find the patch annoying, but he jokes that it’s possessive wives who object most, because “it has a very inviting aroma.” He prefers injections, which are given four times a year.

Googlers searching for a cut-rate way to optimal testosterone levels are taking a foolish risk, Traish says. “Many of the androgen products sold on the Web may not be safe and may not contain the right ingredients. I strongly suggest that no one use androgen products without an evaluation by a physician.”

One unanswered question is about the long-term effects of testosterone treatment. “The National Institutes of Health will not give $100 million for a Women’s Health Initiative–type study in men,” according to Traish. But after following patients on T replacement therapy for almost a decade, he and his colleagues have found no adverse effects.

“Patients on testosterone don’t want to stop,” he says.

Susan Seligson can be reached at sueselig@bu.edu.