Testosterone replacement no answer for ageing males

The use of testosterone to treat symptoms of the male 'mid-life crisis' has a major question mark hanging over it following a hard-hitting article in a leading journal.

The treatment, already controversial, is described as having ‘limited scope’ and is explicitly ruled out for men without symptoms in the Drugs and Therapeutics Bulletin (DTB). The journal questions whether the ‘male menopause’ even exists.

The theory is that since hormone replacement therapy can help women during their menopause then a similar approach – TRT (testosterone replacement therapy) - can help older men. The problem with the theory is that in the female menopause, levels of the female hormone oestrogen plummet and production stops almost completely. In men, by contrast, testosterone levels generally fall by only around 1 to 2% a year from the age of 40 onwards in men and production of the hormone does not stop.

Low levels of testosterone are not an inevitable consequence of ageing, says DTB. Around 80% of 60 year olds and half of those in their 80s still have levels within the normal range for younger men. Moeover even if me do have lower levels these don’t necessarilly lead to menopausal type symptoms.

Evidence 'weak' and side effects 'potentially serious'

Indeed, says DTB, many of symptoms sometimes attributed to low hormone levels, such as low sex drive, erection problems, diminished strength, and low mood, occur in many men with normal testosterone levels. Overall, the evidence that an age-related reduction in testosterone levels causes specific symptoms is weak, says DTB. The published evidence is also inconclusive on whether testosterone given to ageing men with low levels of the hormone improves symptoms, such as poor sexual function or depression.

While TRT probably increases muscle strength and bone density, there are also some 'potentially serious unwanted effects, particularly with long-term use', says DTB. These include blockage of the urinary tract, prostate cancer and the development of breasts. TRT can also aggravate heart disease, epilepsy, and sleep apnoea.

Methods of treatment are also criticised. Patches can irritate the skin; implants require minor surgery, which carries risks; and gels can be inadvertently transferred to other people.

DTB concludes: ‘Clinicians should not offer testosterone therapy without explicit discussion of the uncertainty about its risks and benefits in this population. There is no place for testosterone therapy in older men without symptoms, or without clearly low testosterone concentrations on more than one occasion.’

MHF president and malehealth's resident doctor Ian Banks said: 'Before jumping for the "quick fix" out of a bottle or syringe, men suffering from the so-called "male menopause" should look at the simple things first. Lifestyle, work pressure, alcohol etc. And deal with those. According to this paper the risks of testosterone replacement may well exceed any perceived benefit.'

• Full article: Testosterone for “late onset hypogonadism” in men? (DTB Vol 48; June 2010)