“With all of the direct consumer marketing about medications, patients now are driving the conversation and requesting hormone replacement. A lot of individuals who aren’t urologists are providing testosterone without appropriate follow up,” says Brian Stone, MD, of Jasper Urology. “Synthetic steroids like estrogen and testosterone have a potential risk of cardiovascular side effects including increased risk of stroke or heart attack. Every patient has to be monitored, and they have to be properly selected for this treatment. You should not provide testosterone replacement therapy to a man who has a normal testosterone level.”
Symptoms of low testosterone may include low libido, erectile dysfunction, osteoporosis, sleep disturbance, depression and diminished performance. Many men think hormone replacement can solve these problems, but Stone warns that isn’t always the case.
“There is a misconception that the higher you drive your testosterone level, the more energetic you feel and the more sexual you feel. That’s not true. The American Urological Association has established guidelines that help us identify who should be treated. However, if you are not an urologist you won’t necessarily know and won’t be following these guidelines that attempt to reduce the risk to the public,” Stone says. “Patients need to be evaluated properly and treated only if they have a clinically significant low level of testosterone.”
Treating a man with testosterone replacement unnecessarily can have significant risks, including the “testosterone trap,” Stone says. “Patients can get in a trap because the body doesn’t produce testosterone when the person is taking the replacement hormone. By adding a synthetic form of testosterone, you ultimately shut off your body’s stimulation of the natural hormone. If you take the synthetic version for a while, it’s going to take a long time for the body to resume production of testosterone. Some guys don’t rebound at all.”
Another possible risk of testosterone replacement, in addition to heart attack and stroke, is polycythemia. “Testosterone replacement can cause the bone marrow to produce too many red blood cells, which can result in polycythemia. Having too many red blood cells causes the risk of hyper coagulation which can lead to clots. You can get a clot in a coronary artery or throw a clot to the brain and have a stroke,” Stone says. “Again, if you are not following patients closely or you are not aware that polycythemia can occur, you leave a patient at risk. It happens often when doctors who are not urologists or endocrinologists write a prescription for a patient, give them the medicine and don’t follow up. I think the best thing is for patients to educate themselves about low testosterone and these replacement products. Otherwise, they are putting themselves at risk.”
Stone says the Jasper Urology clinic physicians do a blood test to check a patient’s total testosterone level. If it is low or borderline, they do additional testing before giving the patient hormone therapy. He adds that there are other circumstances in which giving testosterone replacement is not always the best answer. “In Alabama, we see a significant amount of obesity. In a man, belly fat produces aromatase which converts to estrogen. You can’t just give them testosterone; you also have to treat the obesity,” he says. “Giving a significantly obese man testosterone replacement won’t always bring that level back up.”
Stone adds that the Southern diet promotes obesity, and male obesity is driving low testosterone. “We actually are seeing an epidemic amount of low testosterone in very young men. I’ve been an urologist since the 1980s, and in my earlier years we didn’t see this much low testosterone. Now I have 19 and 20 year-old men with low testosterone,” he says.
Stone urges physicians who have patients requesting testosterone replacement to refer the men to an urologist or endocrinologist for evaluation before giving them the synthetic hormone. “I think it is important to have a doctor who is monitoring the patient’s hormone levels closely, watching his blood count and staying on top of his condition. Depending on the patient’s age, he also must be checked for prostate cancer risk. Once the patient has an established regimen that is working, his regular doctor can do the follow up,” he says.
