Symptoms, signs, and laboratory confirmation are all important when determining which patients should try testosterone therapy, according to a panel of experts who shared their views in a Journal of Sexual Medicine commentary.
The article was first published online on May 2, 2014.
Led by Dr. Abraham Morgentaler of Men’s Health Boston, Beth Israel Deaconess Medical Center, and Harvard Medical School, the discussion stemmed from a post-graduate course called “Who is a candidate for testosterone therapy?” This course was given at the World Meeting on Sexual Medicine held in August 2012 in Chicago.
The other panelists were experts in the field: Dr. Mario Maggi (Sexual Medicine & Andrology, University of Florence, Italy), Dr. Mohit Khera (Baylor College of Medicine, Houston, Texas, USA), and Dr. Michael Zitzmann (Centre of Reproductive Medicine and Andrology/Clinical Andrology, University Clinics, Muenster, Germany).
Use of testosterone therapy to treat testosterone deficiency (TD) has increased over the last decade or so. However, there has been little consensus on which patients should start it. Guidelines have been published, but there are limitations. For example, the documents themselves note that the evidence behind the guidelines is poor.
The panel shared their views on testosterone therapy by answering questions on the following topics:
• Symptoms, signs, and blood tests required in order to offer testosterone therapy
• Number of blood tests taken and the timing of those blood tests
• Additional tests of androgen status, if any
• Use of age-adjusted values
• Other routine blood tests used to diagnose TD
• Role of physical examinations
• Monitoring men on testosterone therapy
• Treating men who are symptomatic but have normal serum testosterone
• Treating men who have low testosterone levels but no symptoms
• Thoughts on studies showing heightened cardiovascular risk for men on testosterone therapy
Dr. Morgentaler briefly responded to the questions as well.
The panel agreed on many aspects. For example, testing levels in the mornings was preferred, but not mandatory. They also noted the importance of symptoms. “For me, symptoms are the key,” Dr. Zitzmann said.
They also agreed that recent studies on increased cardiovascular risk for men on testosterone therapy were not reliable. “I am extremely concerned that these poorly designed articles will lead many patients to believe that [testosterone] causes heart attacks. I tell my patients there are far more well-designed studies demonstrating that low [testosterone] increases the risk for a heart attack and [testosterone therapy] decreases [cardiovascular] risk factors,” Dr. Khera said.
However, the panelists differed in other areas. For example, each had different time frames for monitoring patients on testosterone therapy. Also, Dr. Maggi was the only expert to regularly use a screening questionnaire.
In his summary, Dr. Morgentaler wrote, “these expert practices generally follow the main concepts of published guidelines, with some important departures. What impressed me most in learning how these experienced clinicians and researchers approached the problem of identifying men who are candidates for T therapy is their dedication to ‘getting it right.’ Each recognizes the importance that T therapy can have for a man's health and quality of life.”
The Journal of Sexual Medicine
Abraham Morgentaler MD, et al.
“Commentary: Who Is a Candidate for Testosterone Therapy? A Synthesis of International Expert Opinions”
(Full-text. May 2, 2014)