Low Testosterone: A Problem or an Invention?

Many health and medical journalists, and watchdogs of the practice of medicine, have noted a peculiarly American phenomenon: “disease mongering.” As defined by journal PLoS Medicine, disease mongering is “the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments.”

We’ve discussed the topic before, and no doubt will again because it’s found in several guises.

Instead of preventing disease and maintaining health, disease mongering is about conflating common complaints into pathology; it’s about fear and overtreatment, about selling drugs and therapies to “patients” who, by more measured analysis, are really just people with transient or nonexistent problems.

A recent post on KevinMd.com by Dr. Edward Pullen discussed a current representative of disease mongering: low testosterone. “It seems like every day in the office I see at least one man concerned about testosterone deficiency. If you look at the symptoms of testosterone deficiency, most of us have one or more of these symptoms at least some of the time. Fatigue, depression, weight gain, lack of energy, reduced sex drive, loss of physical strength and moodiness are all described as symptoms typical of testosterone deficiency.”

True testosterone deficiency, as defined by the National Institutes of Health, is known as hypogonadism, and can be related to dysfunction in the brain or the testes. It can reflect genetic disorders, or result from trauma, radiation or chemotherapy. It’s common among people with diabetes, chronic pain, metabolic syndrome, inflammatory arthritis, chronic obstructive pulmonary disease (COPD) and kidney disease. But absent a clinically diagnosed reason for flagging testosterone, is it a medical problem worthy of treatment?

HealthNewsReview.org doesn’t think so. It recently alluded to a couple of studies in the Medical Journal of Australia about low-testosterone campaigns (here and here) in a country that has seen at least a twofold increase in total expenditure on testosterone prescriptions in the last two decades, and where direct-to-consumer marketing is not permitted (unlike in the U.S.). Those researchers, finding an insidious effort to juice the drug market despite no medical necessity, called for strict enforcement of the law and sanctions for companies that violate it.

As Pullen explained, defining “low” in testosterone levels is tricky-population estimates range from nearly 3 in 100 men to nearly 40 in 100, the latter figure reflecting people with the diseases mentioned above. Even if it seems appropriate to prescribe testosterone (known as hormone replacement therapy, or HRT), there is cause for pause, because the long term effects are unknown. Some men who take testosterone create additional red blood cells, a condition called polycythemia, that can cause lead to stroke. Although some dire risks are apparent, who knows about the potential for heart disease, prostate enlargement or cancer, all of which are of concern?

It’s reminiscent of the situation with female HRT when, after decades of treatment primarily to relieve the symptoms of menopause, scientific studies showed an increased risk of breast cancer and cardiovascular disease that prompted most practitioners to cease prescribing hormones for most women except for short-term treatment.

Do most of the common, if unpleasant, side effects of menopause really constitute a disorder? Or is pandering to temporary discomfort, even if extreme, more a matter of disease mongering than a reasonable medical response?

Other factors enter into the decision about male HRT. It can be expensive (one review yielded a cost of $330 per month for one brand name), and the the dose delivery can be erratic. Also, according to the Mayo Clinic, common if not life-threatening side effects of testosterone replacement therapy can include:

  • sleep apnea – a potentially serious disorder in which breathing repeatedly stops and starts during sleep;
  • acne or other skin reactions;
  • enlarged breasts;
  • limited sperm production or testicle shrinkage.

As Pullen concluded, “[W]e are really left to decide on a case-by-case basis whether to start men on testosterone replacement therapy. In cases where the testosterone levels are very low and the symptoms are typical I feel pretty good about starting therapy. In cases where testosterone levels are only modestly low or are at the low end of normal but symptoms are present it is much less clear when therapy is indicated. I often feel like my arm is being twisted by some men desperate for some help with their symptoms, and we have to decide on the risk-benefit balance best for them.”

If you wonder if HRT might address symptoms you think are testosterone-related, the first step is to get a blood test identifying your levels. The next step is to ask these questions of your doctor:

1. What is a normal testosterone level for me? Are my symptoms from low testosterone or something else?
2. Are my symptoms temporary and/or intermittent?
3. If I take HRT to alleviate my symptoms, what are the risks?
4. Will I have to take HRT indefinitely?
5. What are the alternatives?

And ask yourself: Am I responding to an advertising campaign? Am I experiencing a natural part of life that requires not medicine but coping skills?

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