Seventy-one-year-old Dennis is very active in his retired life. He and his wife exercise together, attend L.A. Philharmonic concerts, do Sunday crossword puzzles, and they have been having sex at least once a week for many years. About five years ago, he realized his erections were getting weaker, but with Viagra or Cialis he had no trouble performing in the bedroom. This past year, Dennis experienced a decrease in his sex drive. His wife noticed his weight gain, waning energy during their power-walks, and his need for afternoon naps. Blood tests confirmed that he had low testosterone, and he started testosterone replacement therapy (TRT).
According to Sriram Eleswarapu, MD, PhD, urologist at the Men’s Clinic at UCLA, Dennis started to feel better within six weeks and after a year reported a substantial improvement in his sex drive, energy level, and exercise tolerance. Though blood levels are important, that’s not the only determining factor for starting a man on TRT.
“We don’t treat a number—we treat a patient,” says Dr. Eleswarapu. “Some men have blood tests showing low testosterone but are unbothered by symptoms. Other men have low testosterone symptoms, but their numbers may be in the normal range. Every individual’s biology is different. There is no one-size-fits-all approach.”
Dr. Eleswarapu explains that sometimes a man’s testosterone level may be in the “normal” range, but his pituitary gland hormones or his estrogen level may be abnormal in some way. In other words, though his testosterone is “normal,” the rest of his body, including his other testosterone-related hormones, “think” that his testosterone is abnormal. So, at the UCLA Men’s Clinic physicians design a treatment plan tailored to an individual situation, and that treatment plan may include TRT, or it may include other medications, such as estrogen blockers.
Men, Women, and Testosterone
Fatigue, waning sex drive, loss of muscle mass and tone, and weight gain are symptoms that can have many causes. Low testosterone is one of them. If you are male, there are plenty of studies and FDA-approved testosterone treatments. If you are female, there are no FDA-approved testosterone treatments, and clinical studies are fewer. Nonetheless, TRT is available for men and women, and many people do partake of them. There are certainly many benefits documented by high-quality studies. But, there are also risks and caveats.
Insights for Men
The Endocrine Society recommends TRT for men who have hypogonadism, a conditioned diagnosed by low blood levels of testosterone and including such symptoms as erectile dysfunction, low energy, and increased belly fat. The Society discourages the use of it for those who do not have hypogonadism. In short, it’s not for otherwise healthy men looking for a little extra boost of energy and/or sexual verve.
Minor side effects of TRT may include headache, anxiety, acne, and breast swelling and tenderness. It can also cause an elevated red blood cell count, which is more common in men with a history of sleep apnea. A high red blood cell count doesn’t always mean there is a health problem. But there are medical conditions that can cause this response, including a blood disorder in the bone marrow, kidney tumors, and lung diseases, such as chronic obstructive pulmonary disease (COPD).
Some studies have associated TRT with cardiovascular events. Most recently, a 2019 study in The American Journal of Medicine found a 21 percent higher risk of ischemic stroke, and heart attack within the first two years of TRT use. It also noted that TRT may worsen sleep apnea and stimulate benign prostatic hyperplasia.
“There are numerous articles in the scientific literature that document a net benefit of TRT on cardiovascular risk factors, so there is some ambiguity on whether TRT causes cardiovascular morbidity,” says Dr. Eleswarapu. “The treatment can cause a rise in PSA in men with low testosterone as they reach a normal testosterone level. This may trigger the need to evaluate for prostate cancer.”
Update for Women
By the time a woman is postmenopausal, her testosterone level has plummeted to about half of what it was in her 20s. Energy, muscle mass, and libido can all be negatively affected. Ask a medical provider about the use of testosterone treatments for women, however, and the first response you’ll likely get it is “it’s controversial.” That’s mostly due to insufficient clinical trial data, lack of treatment guidelines, and no testosterone formulation designed specifically for women. But there is some progress being made.
In September 2019, the Endocrine Society and 10 esteemed medical societies released the first Global Position Statement on testosterone therapy in women. It provides agreement among experts and medical societies about how testosterone could be prescribed for women. Of course, women have been and are getting these treatments now, but they have been receiving them without strong consensus guidelines to inform therapy.
The Global Position Statement, published in the October 2019 issue of The Journal of Clinical Endocrinology & Metabolism, is based on meta-analysis of 36 randomized controlled trials that included 8,480 participants. The authors conclude that testosterone treatment “significantly increased sexual function including satisfactory sexual event frequency, sexual desire, orgasm, responsiveness, and self-image.” The guidelines are meant for postmenopausal women with hypoactive sexual desire dysfunction (HSDD), essentially low libido. This condition is thought to affect around 32 percent of women at midlife; and, while it’s common for women to lose interest in sex around the time of the menopause and after, the use of testosterone as a treatment offers women an approach that may significantly improve their sexual and related emotional wellbeing.
Amy Rosenman, MD, at the UCLA Center for Women’s Pelvic Health emphasizes that testosterone should be delivered transdermally, meaning absorbed through the skin, not orally, to avoid first going through the liver.
“The ideal patient is a woman with no ovaries, the main source of testosterone in women. These women may benefit from low doses,” explains Dr. Rosenman.
She further adds that in women testosterone is metabolized into estrogen. Therefore, women who should not be taking estrogen are advised to avoid TRT.
Risks of testosterone treatment in women include growing unwanted hair (e.g., on chin and upper lip), acne, changes in voice, weight gain, and clitoromegaly (enlargement of the clitoris). According to Dr. Rosenman, there also may be heart risks that are poorly understood.
Recommendations for Women
Treatment should only be with formulations that achieve blood concentrations of testosterone that approximate premenopausal physiological concentrations. Because no approved female product is yet approved by a national regulatory body, male formulations can be carefully used in female doses. Blood testosterone concentrations must be monitored regularly, so expect to have your blood tested several times a year, especially at the start of therapy. The Global Panel does not recommend oral therapy.
Symptoms related to low estrogen as well as low testosterone levels include discomfort or pain during vaginal penetration, taking longer for the vagina to lubricate before sex, being less responsive to sexual stimulation, and having difficulty reaching orgasm.
Making an Informed Decision
There is a lot of hype surrounding testosterone treatments, as well as a lot of critics disparaging its use. TRT has been helpful to many people. But it isn’t for everyone. It may not be appropriate if you have certain other health conditions. Tell your health-care provider about any conditions you may have or have had, especially the following: breast cancer, prostate cancer, urinary problems due to enlarged prostate, kidney or liver problems, heart problems, sleep apnea or diabetes.
Have a frank discussion with your physician to better understand how, and if, TRT is appropriate for you. Specialists in hormone replacement therapies include urologists, gynecologists, and endocrinologists. Before making an appointment, ask if HRT is within their area of expertise.
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