Testosterone replacement therapy: Do you need it?

By Douglas Sutherland, MD

It comes as no surprise that testosterone replacement has become one of the most common requests urologists receive.

Advertisements for testosterone replacement can be found everywhere, from your local newspaper to radio and TV ads. The ads promise to improve a man’s vitality, his overall health, his sex life, his energy — seemingly without any significant downside.

If you include the popularity of the fitness and sports industries in America, the demand for testosterone has risen dramatically over the past 10 years. Between 2009 and 2013, the number of men who were prescribed testosterone more than doubled.

There is no question that men with medical conditions that reduce testosterone can benefit from testosterone replacement. There is solid medical evidence that a man with low testosterone is at increased risk for heart disease, anemia, bone loss (osteoporosis), diabetes and obesity.

Similarly, when these men are given testosterone replacement, there is clear evidence that their health can improve overall. So why shouldn’t every man be screened for testosterone and treated if it’s low?

The problem remains that we do not fully understand the impact of testosterone replacement on the male body. The evidence is not crystal clear.

First is the concern regarding cardiovascular health. Men who receive testosterone replacement were recently found to have slightly worse atherosclerosis (narrowing of the arteries that supply the heart of blood). This finding is confusing and hard to interpret.

Generally we have understood that narrow arteries increase the risk of a heart attack, and most of the procedures cardiologists perform are designed to restore the diameter of these very arteries. But we also know men who take testosterone are generally less likely to have a heart attack.

Research into this paradox is ongoing, but for now, men with significant coronary atherosclerosis should be wary of starting testosterone replacement.

Second is the concern regarding stroke risk. Testosterone is known to increase the number of red blood cells, and when there are excess red blood cells present, blood clots may form — which can cause stroke (especially if those arteries are increasingly narrow). So men who take testosterone need regular blood tests to make sure they are safe.

Lastly is the matter of urinary function. While the risk of developing prostate cancer due to testosterone replacement has largely been rejected, many men notice that their urinary function declines when taking testosterone, with weaker urinary stream and inability to empty the bladder fully. Such men should be monitored carefully.

If you believe you are experiencing the side effects of low testosterone, make sure to discuss this with your physician, who can determine if it is a testosterone deficiency or another condition.

If you are concerned about low testosterone, talk to your primary care provider, who can refer you to a urologist for treatment as needed.