Monday, June 27, 2011

Understanding Doctors Hostility to Testosterone Replacement Therapy

Understanding Doctors Hostility to Testosterone Replacement Therapy.
 
Dr Andrew Rynne

Traditionally, doctors resistant to the notion that testosterone replacement therapy might be good for one, used to cite the lack of scientific evidence to support their negative views. This is no longer a tactic open to them. Hardly a day goes by now but that there is not some more good news about the value of TRT. Clinical trials are ongoing. As time goes on you may expect to see further positive evidence for the beneficial effects of TRT.
 
What are the delivery systems now for testosterone replacement?

Up to a few short years ago testosterone delivery systems were cumbersome, problematic, erratic and fraught. There were injections that tended to deliver the hormone in bursts that bore no relationship to the levels found in the physiological state. There were implants that were time consuming to insert under the skin and their use carried all the risks common to any minor surgical procedures. They also had a disconcerting tendency to be rejected. And then there were transdermal patches famous for giving rise to local skin reactions and dubious blood hormone levels.

All of these have now largely been replaced by either a transdermal gel – Testogel, Testim, Androderm etc or a long-acting deep intramuscular injection called Nebido and containing 1,000 mg of Testosterone Undecanoate in 4ml oily suspension. This is given every twelve weeks although in practise this is usually increased to be given once every ten weeks. Also, in practise, I find it easiest to prescribe the gel for the first two months before moving on to the intramuscular version, given at 0,6 and then every 10 weeks.

Expensive and unreliable hormonal assays are now a thing of the past.?

 In a study conducted in 2007 the authors concluded as follows:        

Though laboratory assays can support a diagnosis of androgen deficiency in men, they should not be used to exclude it. It is suggested that there needs to be greater reliance on the history and clinical features, together with careful evaluation of the symptomatology, and where necessary a therapeutic trial of androgen treatment given.

It has made things a lot easier, not to mention a lot less expensive, for general practitioners considering TRT for certain patients. Today, doctors rely much less on hormone assay when deciding who and who should not be considered for testosterone supplementation. Nowadays I tend to take the pragmatic or empirical approach. If a sixty-three year old man comes to me complaining of mild depression and erectile dysfunction not fixed by Viagra then I would immediately think of TRT.

Or, if a seventy-two year old man attends with Type 2 diabetes and loss of libido, TRT will at the very least cross my mind such that I will  discuss the ins and out of this suggestion with the client. The same holds true for the Metabolic Syndrome. Presented with an overweight, hypertensive, and hyperlipidemic man in his seventies, with a strong family history of coronary artery disease, I would, with very little hesitation, strongly consider TRT as a wise choice for him. In any of these situations, I would consider PSA as the only blood test necessary to do and even at that reluctantly.

As for gauging the clinical indications or efficacy of TRT, in the absence of blood androgen levels, we have the self-assessment tool known as the ADAM test. Here the client, not the doctor, scores himself against a series of graded questions to do mostly with his quality of life. If this score is low then perhaps TRT is worth considering. If after a few weeks on TRT his score remains low then perhaps discontinuation of TRT might be equally meritorious. This is pragmatic medicine. It can be as simple as that.

Does testosterone therapy cause prostate cancer?
 
There is no evidence that raised testosterone levels causes or increases the risk of prostate cancer. Prostate cancer is a disease of older men with reduces testosterone levels. It is not a disease of younger men with high testosterone levels. So, if anything, testosterone would appear to be protective of the prostate gland against malignancy. I am not making that case here though. 

It has been observed in peer review study that by significantly reducing testosterone levels with the use of finasteride this can reduce the incidence of prostate cancer by some 25%. Does this not therefore strongly suggest that the increase of testosterone levels would have the opposite effect and increase the incidence of prostate cancer?

Yes indeed it does. But such a proposition is no more than a corollary and as with all corollaries it has to be accepted without any supporting evidence. You must accept it as “logical” and leave the field of clinical science and evidence based medicine behind you.

Corollaries work very nicely in religion and philosophy. God is good. If you don’t believe in God then clearly you do not believe in goodness. But do they work in medicine? I hardly think so. It is a tad annoying to see that the very people shuffling on the high moral ground of peer review science and baying for evidence based medicine only, can themselves so readily abandon such lofty principles when it suites them. There is a double standard at play here and it is not equitable. 


Does testosterone therapy not risk accelerating the growth of a pre-existing yet to be detected prostate cancer?   

This might be your Becher’s Brook when it comes to supporting TRT. But that’s all it is, a jump and like most jumps you can get over it. Castration, surgical or pharmaceutical, causes prostate cancer to regress albeit temperately. Therefore, watch the slight of hand here now, increased testosterone levels will or might fan the flames of an existing small and contained prostate cancer. Isn’t that only logical?

Indeed it is only logical. Note the imagery often used – fan the flames. Logical and emotional even. But is it scientific? Is it peer review and evidence based? No it is not. It is another corollary for which there is not one shred of clinical or scientific foundation to support. Indeed, what few studied there have been to date have all failed to demonstrate any correlation between raise testosterone levels and prostate cancer. And yet, when considering a man for TRT we still consider it necessary to apply that monkey-wrench of an instrument called PSA.

Summary.

Debate and controversy continue to rage around the subject of testosterone replacement therapy. Clinical trials are ongoing and so far have delivered good news and even hint at an expanding potential range of disease processes related to ageing where TRT may be indicated.

Certainly, in the last ten years, we have moved a long was from thinking of TRT as a mere bedroom fodder, libido booster and adjunct to ED treatments. Evidence is slowly emerging to support the proposition that testosterone has a role to play in the reduction of dementias – senile and Alzheimer’s, the management of type two diabetes, hyperlipidemia, coronary artery disease, metabolic syndrome and osteoporosis.

The academic naysayers and detractors remain alive and well of course although the firmness of the high moral ground upon which they once stood maybe crumbling somewhat.       

Dr Andrew Rynne www.doctorrynne.com

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