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Testosterone Therapy: Mayo Clinic Radio

welcome back to Mayo Clinic radio I'm

dr. Tom shibez and I'm Tracy McCray

Tracy all made all of us guys experience

a natural and a normal decline in

testosterone levels as we get older and

typically it's about 1% a year after the

age of 40 so when you're 65 you've got

probably 25% less testosterone than you

did when you were 40 and in some men

that declining testosterone level causes

a decrease in energy and a decrease in

sex drive but help is available through

testosterone therapy a treatment that

has become increasingly popular in

recent years due to the aging baby

boomer population a series of seven

clinical trials sponsored by the US

National Institutes of Health is being

used to assess the effectiveness of

hormone therapy in men 65 or older with

symptoms related to low testosterone

levels so here to talk to us about

testosterone is urologist dr. Landon

Trost dr. Trost good to have you on the

program well thank you for having me on

the program appreciate being with you so

for a woman when she reaches menopause

the estrogen sort of drops dramatically

for a man it just sort of gradually

subsides fades away in some cases that

that's the case there are of course

disease states where their testosterone

will drop immediately or after cancer if

you're treating for testicular cancer

something like that but in the majority

of men it is this slow steady decline

and in these clinical trials at c7

clinical trials what do they show is it

a good idea or not well and I'd say

testosterone in general for the past

decade or so has been increasingly

popular increasingly investigated like

you mentioned with the women's health

and estrogen that was really about the

1990s or so we had a big push towards

supplementation should there be estrogen

supplementation and so on and this is

kind of the male equivalent to starting

to come of age and these particular

trials in general were an attempt to

look at this in a more rigorous fashion

so there were many small trials with

either retrospective in nature are very

limited kind of randomized trials and

here the NIH essentially got together

with some of the trials to put together

a more robust set of data so this

particular one was funded by industry

but the goal was to really see does

testosterone work or not

and the key conclusion of the trials is

that yes indeed it does work and

appropriately selected men but it's a

modest benefit in general so it's not

gonna it's not the Fountain of Youth

it's not gonna make you 20 years old

again

I think the key might be appropriately

selected men I think that might be it so

what does that mean well yeah but first

of all what are we treating here is it

really true has it been shown that if is

testosterone levels go down that it does

indeed decrease energy and decrease sex

drive

yep so it's a good question I think

there's two parts to that question in

certain men who have like metastatic

prostate cancer for example for many

years they've been treated by cutting

out all the testosterone either through

orchiectomy or through removing their

testicles I was trying to think of a

good way but in those cases no question

we see a big and broad sweeping side

effects and that includes energy hot

flashes decreased bone mass diabetes all

sorts of large and significant side

effects throughout the body wait am I

get hot flashes yep yeah so if you cut

testosterone abruptly a percentage will

get pretty severe hot flashes from it so

we do know that the bigger question is

if you have a very slow and steady

decline do you get different symptoms

with it and it appears that a lot of

these symptoms are based on certain

thresholds so the lower your

testosterone goes the more likely or to

have significant symptoms but perhaps

even more concerning is there have been

several trials showing now that as if

you look at men with low testosterone

versus normal testosterone values those

who have low don't live as long they

have a much higher rate of hypertension

hyperlipidemia diabetes high blood

pressure fat's in their blood yes

exactly and so we've known for some time

now that low testosterone is associated

with multiple conditions and now we're

getting more and more data showing what

can supplementing testosterone do to

some of these disease states okay so you

if you watch TV

it suggests that every guy out there has

got low tea and that ought to be taking

some sort of supplement but there must

be some criteria that you use to decide

who's a candidate get this and who is it

a selection of the men that's what I

want to know no it's a

the golden question I think - no

question so in the early 2000s this

became very much direct-to-consumer

marketing and this drug so testosterone

supplementation has been grandfathered

in by the FDA for this so it's a very

appealing target for a lot of companies

because they don't have to invest a lot

of money in it they don't have to go

through regulation for it so there was

really a boom and it became a above 1

billion dollar industry very quickly in

the 2000s just the stuff you could get

over-the-counter well in or you'd have

to still get a prescription for it but

as far as this idea of all men have low

tea and this is going to reverse all

these symptoms so there is no question

that the appropriately selected men

which is essentially men who are most

guideline societies that put this around

280 as far as your blood test value for

testosterone anyone below that is likely

a viable candidate for testosterone

supplementation if they have symptoms of

low testosterone so you shouldn't sorry

you shouldn't take it unless you have

seen a position and had your

testosterone level checked yep oh that's

correct and there are several studies

actually showing that if you do

supplement and you're in the normal

range there's no added benefit if you

compare it to placebo or a sugar pill or

whatever it's equivalent to that so this

idea of over supplementing really should

be non-existent just gives you expensive

urine yep yep how is testosterone

therapy given is it a cream or is it a

pill how does it happen there's multiple

different ways to do it now so in the

United States some of the most common

are either injections or through a

topical gel

there are also patches there's things

you can put in your gums you can put in

your nose you can do long-acting

injections you can put pellets under the

skin there's a million different ways to

do it so in Europe there's an oral pill

available as well that may be available

in the United States at some point and

then there's off-label methods of giving

it as well through other agents such as

clomid or Arimidex or other things so

they're right as of today in the United

States there is not a testosterone pill

that you can take there's an off-label

version so you can take one like a

clomid for example it's a selective

estrogen receptor modulator it's a

specific type of pill and it indirectly

raises testosterone but you can't take

an oral form

testosterone that's correct just like

you can in Europe mmm are there a nice

I'm sorry go ahead so do you think it

will be coming here in the near future

it's always tough to predict regulatory

things so it would just be you know pure

speculation on that it seems to have

merit but the FDA in general is

concerned about an overreach of of using

testosterone it was originally indicated

for you know young boys who never went

through puberty who needed testosterone

supplementation and now it's been

broadened into this very large category

if all men as they age and or the

majority of men as they age and get low

testosterone values so are there any

risks to testosterone therapy there are

there generally mild has long and and

the goal is if you keep someone in the

normal range so we do see some who have

used it for building muscles and things

like that and that's a whole different

discussion but if you keep it within the

normal range we do monitor things like

your the red blood cell count so how

thick your blood is and we also monitor

PSA for things so the known risks are it

may raise your red blood cell count it

can increase acne it could potentially

increase hair loss slightly there's so

there's small things like that that we

monitor the risks as far as heart

disease strokes those are really unknown

they're unlikely but we just don't have

enough data or enough men to really know

the risk for prostate cancer is really

nothing if it does not cause new onset

prostate cancer alright so the bottom

line is there may be some men who would

benefit from testosterone therapy but

before you do that see your physician

have your testosterone level checked and

only use supplementation or testosterone

if it's low it's an excellent summary

and does insurance cover it at this

point insurances are variable so most of

them will cover some degree but a lot of

times there's out of pocket of up to a

few hundred dollars each month alright

there's the bottom line on testosterone

therapy dr. Landon trost urologist Mayo

Clinic thanks for being with us thanks

for having me and that's our program for

this week