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“Low T”: The triumph of marketing over science

A man on TV is selling me a miracle cure that will keep me young forever. It’s called Androgel…for treating something called Low T, a pharmaceutical company–recognized condition affecting millions of men with low testosterone, previously known as getting older.

The Colbert Report, December 2012

 

And now for something completely different…sort of.

After writing so much about the latest developments in the ongoing saga of the cancer doctor who is not an oncologist and not a legitimate cancer researcher, plus a rumination on what’s up with President Obama’s nominee for Surgeon General and our favorite form of unscientific medicine, so-called complementary and alternative medicine (CAM), also known as “integrative medicine,” I thought it was time for a change of pace. I wasn’t sure what I was going to write about as Sunday rolled around, but fortunately, as sometimes happens, the New York Times dropped a topic right in my lap, so to speak, both figuratively and literally. It comes in the form of a long article on something that directly concerns men of a certain age, which unfortunately happens to mean men of my age and older. I’m referring to what pharmaceutical company advertising campaigns have dubbed “low T,” short for low testosterone. It’s not clear how the term “low T” originated but Dr. Abraham Morgentaler, founder of Men’s Health Boston, claims to have coined the term when his patients were embarrassed by their difficulty pronouncing the word “testosterone.” Other sources report that it was Solvay Pharmaceuticals that coined the phrase. It doesn’t really matter where the term “low T” came from. The term has stuck, even though the more “correct” medical term would be hypogonadism, as in a man’s testes not working.

The NYT article appears, very appropriately, not in the Health section of the paper, but rather in the Business section. Indeed, if you believe the hucksters and manufacturers of testosterone replacement therapy, pretty much every man over the age of 40 or 50 is prone to a devastating lack of testosterone that must be replaced, preferably by products provided by big pharma like AndroGel. Indeed, the NYT article, written by Natasha Singer, is entitled ‘Selling That New-Man Feeling,’ and she makes a very good case that selling is what it’s really all about, more so than science-based medicine. Since we haven’t addressed the issue of “low T” in over three years, this NYT article seemed to me like the perfect excuse to revisit the topic, looking at how pharmaceutical companies and doctors sell the concept and whether or not there has been any new evidence to guide us in the last three years.

Apparently, 70 year old men should be as virile as 20 year olds

Three years ago, both Peter Lipson and Harriet Hall wrote about the phenomenon that’s been sweeping the men’s health world over the last five years or so of diagnosing and treating “low T.” Peter acknowledged that “low T” can be a real phenomenon but pointed out that it generally only affects small numbers of men. Harriet quite rightly pointed out that testosterone, contrary to the way it’s being marketed, is not an anti-aging panacea. None of this is to say that legitimate diagnoses of low testosterone shouldn’t be treated, but questions proliferate. How low is really “too low”? What are the goals of treatment? Do low or low-normal testosterone levels actually cause the symptoms being attributed to them? For instance, if you wander over to the AndroGel site and look at the sorts of symptoms being attributed to “low T,” you’ll find:

Signs and symptoms of Low Testosterone may include:

  • Fatigue or decreased energy
  • Reduced sex drive (libido)
  • Sexual dysfunction (weak erections, fewer erections)
  • Depressed mood
  • Increased body fat
  • Reduced muscle mass and strength
  • Decreased bone strength
  • Loss of body hair (less frequent shaving)
  • Hot flashes, sweats

There’s then a test, which takes the form of a series of questions:

  1. Do you have a decrease in libido (sex drive)?
  2. Do you have a lack of energy?
  3. Do you have a decrease in strength and/or endurance?
  4. Have you lost height?
  5. Have you noticed a decrease in your enjoyment of life?
  6. Are you sad and/or grumpy?
  7. Are your erections less strong?
  8. Have you noticed a recent deterioration in your ability to play sports?
  9. Are you falling asleep after dinner?
  10. Has there been a recent deterioration in your work performance?

Just for yucks, I took the quiz, and this is what I got back:

LowT

Yes, it turns out that AbbVie, the drug maker behind AndroGel, is very concerned that I might have “low T” and really thinks that I should get myself checked out. I think I’ll probably pass, given the origin of this questionnaire, which is known by the acronym ADAM, which stands for the Androgen Deficiency in Aging Males test:

More than a decade ago, a Dutch pharmaceutical company, Organon BioSciences, asked Dr. Morley to devise a screening questionnaire covering symptoms common to older men with low testosterone. The way Dr. Morley recalls the drugmaker’s instructions, “they said, ‘Don’t make it too long and make it somewhat sexy.’ ”

In return, he says, Organon gave $40,000 to his university for research into the effects of testosterone on muscle. Along the way, Dr. Morley’s quiz acquired an official name that emphasized its intended audience was older men: the Androgen Deficiency in Aging Males, or ADAM, test.

That test has become standard fare on brand-name drug sites like androgel.com and on informational sites like AbbVie’s IsItLowT.com — where the ADAM test has been re-branded as the “ ‘Is It Low T?’ Quiz.” If the questions drive many men to identify themselves as low-T sufferers and visit their doctors seeking remedies, well, that is their purpose.

Indeed, it is, which is why I failed it. Particularly amusing is the section where it asks if you’re falling asleep after dinner. A particularly pithy quote was included from Dr. Adriane J. Fugh-Berman, an associate professor at Georgetown University Medical Center in Washington and director of Pharmed Out, who quipped, “Depends how long after dinner. We all do eventually. It’s called sleep.” Also, I would add, if it’s a particularly carb-rich dinner, I might indeed doze off not long after. Clearly many of us who will be partaking in a mere few days of our yearly Thanksgiving feasts suffer from low T!

It turns out that these “low T” advertisements take advantage of a loophole in the law. The FDA and Federal Trade Commission carefully monitor pharmaceutical company advertising. In particular, the FDA looks out for drug companies that advertise “off-label” uses for their drugs; i.e., uses for which the drug is not FDA-approved. As we’ve discussed from time to time here at SBM, off-label prescribing is a common and often accepted practice that is not necessarily outside the purview of science-based medicine, given that FDA approval can lag behind the evidence for a new indication for a drug. However, pharmaceutical companies are not permitted to promote such uses. After all, if they could market drugs for off-label uses, then why bother going to the trouble of doing all those expensive and pesky clinical trials to gain approval for new indications?

There is one sort of advertising campaign, however, that the FDA doesn’t really regulate. You can look at it as a similar end run around FDA regulations used by supplement manufacturers when they make vague “structure-function” claims. In this case, the end-run is known as “unbranded” promotions or “disease-awareness” campaigns. These are promotions that do not advocate the use of a specific brand of a drug and/or promote “awareness” of a condition:

The Food and Drug Administration closely regulates advertisements for brand-name prescription drugs, but does not generally regulate unbranded campaigns. That two-track system, says John Mack, an analyst who runs a blog called Pharma Marketing, has enabled companies to position low T as a malady with such amorphous symptoms — listlessness, increased body fat and moodiness — that it can be seen to afflict nearly all men, at least once in a while. Drug makers also promote low-T screening quizzes directly to consumers, Mr. Mack says, in an effort to prompt men to seek testosterone prescriptions from their doctors.

For this sort of campaign:

Earlier this year, Medical Marketing & Media, a trade magazine, named two AbbVie executives as “the all-star large pharma marketing team of the year” for promotions of AndroGel and unbranded efforts to advance low T.

“It didn’t hurt that baby boomers have proven less than shy about availing themselves of any product that they believe will increase their quality of life,” an article in the magazine said. The article lauded AbbVie’s DriveForFive.com, an unbranded site that encourages men to have regular checkups and to ask their doctors about five tests, among them tests for cholesterol and blood pressure — and testosterone.

Mr. Freundel of AbbVie described the effort as “a national disease-awareness initiative aimed at encouraging men to take a more proactive approach to their health.” The F.D.A., he added, encourages companies to develop such initiatives “because they serve an important role by enhancing awareness of health conditions.”

Described in Medical Marketing & Media thusly:

AbbVie took a taboo topic and, via a cagey media-and-marketing presence, rendered it less wince-inducing among its target audience. It did so at a time when a number of critics voiced their concerns that the marketing and use of testosterone-boosting products had gotten ahead of the science.

Notice how blatant MMM is in trumpeting this as a triumph of advertising over science. AbbVie overcame all those nasty doctors trying to tell people that there’s no good science to indicate that all these millions of men need testosterone replacement therapy. I guess AbbVie showed them! Indeed, this marketing campaign, coupled with other, similar campaigns by other testosterone manufacturers and physicians specializing in men’s health, testosterone prescribing is way, way up. Indeed, a recent study in the Medical Journal of Australia concluded:

In the absence of any new indications, off-label testosterone prescribing has increased in most countries in 2000–2011, especially over the last half of the period. The increased testosterone prescribing appears to be primarily for older men and driven by clinical guidelines that endorse testosterone prescribing for age-related functional androgen deficiency (andropause). By eliminating the fundamental distinction between pathological and functional androgen deficiency, these guidelines tacitly promote increased testosterone prescribing, bypassing the requirement for high-quality clinical evidence of safety and efficacy and creating dramatic increases in prescription of testosterone products.

In the U.S., monthly use per 1,000 population increased nearly ten-fold between 2000 and 2011; in Canada, the increase in usage was nearly 40-fold, even though it started at about the same rate in 2000. It is truly astounding how much the use of testosterone supplementation has increased in developed countries. It’s almost impossible to escape the advertising. It’s in newspapers, on television, and all over the Internet. As I’ve seen it quipped, ads for “low T” seem to be directly competing with the ads, ubiquitous since the late 1990s, for erectile dysfunction drugs. One wonders when “awareness” of “low T” will surpass awareness that, seemingly, older couples must sit side-by-side in separate bathtubs before getting it on, as anyone who’s seen a Cialis ad knows.

But I digress. Let’s take a look at “low T” and what the scientific evidence, rather than the marketing hype, says about it.

Low T, high T, fitting testosterone to a T

The Is It Low T? website claims that “millions” of men in the US suffer from “low T.” Perusing the various ads and promotional materials, one will soon see an estimate of 13 million men in the US over the age of 45 suffering from “low T.” This estimate is sometimes attributed to the American Diabetes Association, but if you look at the link to a page about low testosterone on the ADA website it says nothing about the prevalence of this condition, other than that it is “common.” As Jim Laidler pointed out in the comments of Harriet’s post on the topic, according to the US Census Bureau, there are over 53 million men over age 45 in the US as of 2010. This would mean that nearly a quarter of men over 45 have “low T.” It’s a figure that seems rather high and difficult to believe.

Part of the problem is that as is the case with estrogen levels in women, testosterone levels in men begin decreasing after the age of 30. The topic was reviewed well in the New England Journal of Medicine nine years ago, so this is not new information. Contrary to the abrupt and rapid decrease in sex hormone levels that occurs in women when they enter menopause, in men testosterone levels decrease more slowly, with the serum total testosterone concentration decreasing from a mean of about 600 ng/dL (20.8 nmol/L) at 30 years of age to a mean of about 400 ng/dL (13.9 nmol/L) at 80 years, although, the review noted, the range is wide at all ages. However, the “normal” range for serum testosterone levels varies with age, decreasing as a man ages. In younger men, the low end of the normal range is generally considered to be around 300 ng/dL, and that is often the level recommended as the cut-off by the “low T” websites.

Testosterone levels also vary considerably in that they can be affected by illness and medications such as opiates and glucocorticoids. They also can vary significantly due to circadian and circannual variations, episodic secretion, and measurement variations. In the circadian variation, peak levels are noted in the morning, although this variation is less in older men. Indeed, even with this blunting of the circadian variation of testosterone levels, a significant proportion of men over 65 with low testosterone levels in an afternoon blood draw will have normal levels in a morning blood draw. Depending on the specific male sex hormone, the various standard deviations imply that a clinician can expect to see a difference exceeding 18% to 28% about half the time when two measurements are made on the same man and a difference exceeding 27% to 54% a quarter of the time. Also, 15% of healthy young men will have a testosterone level below the normal range in any 24 hour period. That is why the Endocrine Society, in its clinical practice guideline for Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes, emphasizes that “day-to-day variations in serum testosterone concentrations were found to be sufficiently large that single testosterone measurements were inadequate to characterize an individual’s levels, and at least two testosterone measurements were needed to diagnose androgen deficiency with greater confidence.”

Funny, then, that a recent study (the same study that found skyrocketing rates of androgen replacement prescribing) also found that among all new androgen users from 2001 to 2011, only 74.72% had had their testosterone level measured in the year prior to starting to take androgen replacement. That means slightly over one quarter of men started on testosterone had never been shown to have low testosterone levels! Given this result, one wonders how careful a workup was done before prescribing testosterone replacement. After all, there are multiple forms of hypogonadism, primary and secondary. Primary hypogonadism is due to failure of the testes to make adequate testosterone, while secondary hypogonadism is due to a problem in the hypothalamus or pituitary gland, the parts of the brain that signal the testes to produce testosterone. The hypothalamus produces gonadotropin releasing hormone, which signals the pituitary gland to make the follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone. Either type of hypogonadism may be caused by an inherited (congenital) trait or something that happens later in life (acquired), such as an injury or an infection, and there are specific workups and tests that need to be done to differentiate between the two, as detailed in the Endocrine Society’s guidelines.

For these men, most likely, testosterone was prescribed for some of those vague symptoms that the “Low T” websites promote as being due to low testosterone levels or to make a man “feel younger.” These are the sorts of symptoms that are relieved by testosterone in testimonials, like this one by former pro football player Daryl “Moose” Johnston, whose complaints were mainly:

I was feeling more tired than usual and I noticed that I was having trouble keeping up with my regular activities. These signs were pretty subtle at first, but it didn’t take long until they started to get in the way of things I loved to do, like exercising. As an athlete and someone who has been active my entire life, I knew something wasn’t right. That’s when I decided to see my doctor.

There’s a term for symptoms like that: Getting old. Yes, it sucks, particularly if you used to be a professional athlete and your identity is heavily invested in being physically fit and active. It often hits athletes hard when they realize that they can’t keep up with young men anymore. But how does one distinguish symptoms that are really due to “low T” from the normal changes that men (and women) experience as they get older? I’m experiencing these sorts of things, even though I was never an athlete and never particularly physically active. I highly doubt it’s due to “low T.” It’s probably because I’m getting older and, frankly, because my lifestyle and diet aren’t the greatest.

All of this brings me to asking whether there is anything to the claims that replenishing low or borderline-low testosterone levels will correct many of the symptoms for which testosterone replacement therapy is prescribed. In considering this question, it is useful to frame it as a series of four questions asked by Peter Lipson three years ago:

  1. Is there a plausible connection between testosterone levels and certain symptoms?
  2. What is a normal testosterone level?
  3. Are there specific symptoms that correlate with lower levels?
  4. Does replacement therapy correct these symptoms?

I’ve already discussed #2 in detail. Question #1 would suggest that, at the very minimum, symptoms of sexual dysfunction, such as decreased libido, infertility, and erectile dysfunction, could be plausible consequences of low testosterone levels. After all, testosterone is the primary male sex hormone. Besides libido, fertility, and sexual function, testosterone also influences energy and stamina, mood, cognitive functioning, bone density, red blood cell production, and maintenance of secondary sexual characteristics.

However, such symptoms can be caused by many things. Depression and medication side effects, for instance, can result in decreased libido. Atherosclerotic vascular disease can result in erectile dysfunction due to decreased blood flow, as can damage to the nerves controlling erection. A number of studies have looked at the symptoms attributed to low testosterone with mixed results, such that it is not unreasonable to characterize the clinical importance of age-related decreases in testosterone as controversial. For example, a recent study of middle-aged and elderly men found that only poor morning erection, low sexual desire and erectile dysfunction were associated with low testosterone levels. Other symptoms, such as decreased vigorous activity, difficulty walking more than one kilometer, fatigue, and loss of energy, all symptoms frequently attributed to “low T,” correlated poorly with testosterone levels. So the answer to #3 really only includes primarily symptoms of decreased libido and erectile dysfunction.

There are other clinical problems that have been attributed to low testosterone, but it is hard to determine whether they are causative or a consequence of the conditions associated with low testosterone. For example, metabolic syndrome has been associated with low testosterone levels. Although testosterone levels were associated with metabolic syndrome, this relationship appeared to be associated with lipid categories, hs-CRP, BMI, and insulin resistance levels and did not appear to be an independent marker for metabolic syndrome. Similarly, a recent review of the literature concluded that low testosterone is associated with depressive disorders but that “there is insufficient evidence to conclude that low testosterone level routinely leads to major depressive disorder in men,” while another recent review concluded that “men with COPD [chronic obstructive pulmonary disease] have clinically relevant lower than normal TT levels” but that “insufficient evidence from short-term studies in predominately male COPD patients suggests that testosterone therapy improves exercise capacity outcomes, namely peak muscle strength and peak workload.”

One of the strongest claims made by advocates of treating “low T” is that low testosterone levels are associated with cardiovascular diseases, such as atherosclerosis, hypertension, and myocardial infarction. A “hot off the presses” review from Belgian researchers based on the literature from 1970 to 2013 concluded:

On the one hand, a modest association is suggested between low endogenous T and incident cardiovascular disease or cardiovascular mortality, implying unrecognized beneficial T effects, residual confounding, or a relationship with health status. On the other hand, treatments with T to restore “normal concentrations” have so far not been proven to be beneficial with respect to cardiovascular disease; neither have they definitely shown specific adverse cardiovascular effects. The cardiovascular risk-benefit profile of T therapy remains largely evasive in view of a lack of well-designed and adequately powered randomized clinical trials.

Also hot off the press, however, is a cohort study published JAMA from the University of Texas Southwestern involving 8,709 men with low testosterone undergoing coronary angiography in the VA medical system, of whom 1,223 started testosterone therapy after a median of 531 days post-angiography. The investigators found that testosterone replacement therapy was associated increased risk of mortality, MI, or ischemic stroke. The effect sizes weren’t huge, but the results were consistent with an earlier small randomized, placebo-controlled trial of testosterone replacement therapy in men 65 or older with limitations of mobility had to be stopped because of a higher number of adverse events in the testosterone group.

There’s no doubt that for men with true hypogonadism, testosterone replacement therapy can have definite therapeutic effects, as both Peter Lipson and Harriet Hall have described, but that’s not what we’re talking about here. Moreover, testosterone replacement has known adverse effects, including sleep apnea, elevated red blood cell count, heart disease, acne, benign prostatic hypertrophy, breast enlargement, reduced sperm production, and shrinkage of testicles. It might also have unknown adverse effects over the long term, as some of the studies cited above show. At the very least, it is not the panacea that it’s advertised as.

Low T: When science meets marketing, marketing wins

The best summary of the controversy over “low T” that I’ve seen appeared in JAMA in August. It was written by Lisa M. Schwartz and Steven Woloshin and entitled Low “T” as in “Template” How to Sell Disease. Schwartz describes that template in terms of three strategies:

  • Lower the bar. By this, Schwartz means to broaden the criteria for a “disease” beyond what was previously accepted, evidence or no evidence. In other words, “lower the bar” for diagnosing that disease, so that more people need “treatment.”
  • Raise the stakes. This involves increasing the claims for the harm that comes from not treating the new condition and the benefits of treating the condition. Schwartz writes: “It is one thing to tell men that Low T can make them grumpy; it is another to say that it can kill them. Messages raising the stakes about Low T have appeared regularly in scientific meeting reports and journal articles7 and often make their way into the news (“Low testosterone could kill you,” according to ABC News).”
  • Spin the evidence. This one is self-explanatory. As Schwartz puts it: “Testosterone therapy results in only small improvements in lean body mass and body fat, libido, and sexual satisfaction, and has inconsistent (or no) effect on weight, depression, and lower extremity strength. Whether these effects are big enough to matter to patients is unknown. Nor is it known whether they are big enough to outweigh the harms of testosterone therapy, i.e., polycythemia that may increase thromboembolic events, edema, serious hepatotoxic effects, gynecomastia, worsening of sleep apnea, prostate enlargement, and rise in prostate-specific antigen level (and potential increased risk of prostate cancer).”

All of these things are going on with respect to testosterone replacement therapy. There is a paucity of evidence that “low T” is the problem that it is advertised to be and even less evidence that testosterone replacement therapy corrects the problems attributed to “low T.” Before pharmaceutical companies launch big money campaigns to make millions of men “aware” of low T, they should be required to do what they have to do before introducing a new drug for a new indication: the appropriate large-scale randomized trials to demonstrate that testosterone therapy for otherwise-healthy aging men whose testosterone levels are below the normal range for young men does more good than harm. Right now, we don’t have that evidence, and we’re not likely to get it from pharmaceutical companies.

Posted in: Clinical Trials, Pharmaceuticals, Science and the Media

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67 thoughts on ““Low T”: The triumph of marketing over science

  1. shrike1978 says:

    I have true hypogonadism. At age 28, my testosterone levels were measured at between 18-22 ng/dL over the course of 3 tests. Androgel has been amazing for me. It fixed sleep problems, increased my energy, and stopped and slightly reversed some minor gynomastia. Now at age 35, we still maintain a fairly low level overall overall, about 400 ng/dL, but it’s enough to

    I say that to say this, I don’t think there’s anyone who is more annoyed by the over-marketing that me. Conflating my medical condition with natural aging is virtually criminal.

    1. Young CC Prof says:

      “I say that to say this, I don’t think there’s anyone who is more annoyed by the over-marketing that me.”

      You are not alone in feeling that way. When something like this happens, a real but fairly uncommon medical condition gets co-opted, either by a drug company or a woo company, diagnostic criteria broadened to the point that a huge percentage of the population qualifies, the people who tend to get most angry about it are the ones that really have the condition, whether it’s hypogonadism, lyme disease, or anything else.

  2. skipbidder says:

    Went to an academic half-day with the Internal Medicine residents. Endocrinologist was speaking. About 40 minutes dedicated to hypogonadism, but he was pitching very widespread test for low testosterone in the elderly, and that we should not age-adjust our norms. The criteria he had in mind included fatigue or depressed mood (didn’t have to rise to Major Depressive Disorder or even Dysthymia levels). I’d be testing the majority of my male nursing home population in that case.

    Testosterone is a Beers List med, considered indicated only for treatment of moderate to severe hypogonadism. (For the reasons that you bring up regarding cardiac complications, as well as concern re: prostate cancer.)

    The Beers List is the American Geriatrics Society’s list of Potentially Inappropriate Medications for Use in Older Adults. Testosterone was added in the recent update (with a quality of evidence rating of Moderate, and a strength of recommendation of Weak).
    http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf

  3. windriven says:

    I am sure that we in the PNW are not alone in having physicians marketing testosterone. Seattle is home to one Jerry Mixon, MD, proprietor of Longevity Medical Clinic. Mixon is a family doctor and as far as I have been able to find, not board certified in anything. What he does have is a radio show, several clinics, frequent ‘seminars’ that are actually marketing programs, a storefront selling supplements on his clinic website. Oh, and he has been sanctioned for inappropriate sexual contact with a patient and on June 27th was put on a five year probation, $10,000 fine, prohibited from advertising, prescribing or administering HGH, practice reviews and a mandated annual appearance before the WA State Medical Commission.

    But he’s still flogging testosterone. And apparently doing quite well, thank you. The guy should have been a chiropractor.

  4. goodnightirene says:

    Personally, I have been mostly relieved that hubby’s t-levels seem to have subsided after age 50. One doesn’t have to be frigid to embrace a less intense sex life. There are other benefits that go with decreased libido, such as decreased aggression, hence a ride in the car is more pleasant these days as well.

    1. Republicus says:

      That’s interesting, since I have a high libido, but have never been an aggressive driver. In fact, I hardly ever get angry at all.

  5. David Gorski says:

    I’d be testing the majority of my male nursing home population in that case.

    Which is exactly what AbbVie would like to see.

  6. davidrlogan says:

    Interesting and detailed treatment as always, Dr. G. Have a nice morning…

  7. Jerry says:

    Oncologists are killing more people annually with chemotherapy and radiations than Burzinsky does. That’s a fact.

    1. windriven says:

      Really Jerry? What is the source of your “fact?” Do you have a citation or are you just making it up? And how do you explain the increases in 5 year survival over the last 40 years if oncologists are killing so many patients?

      Let’s see the facts Jerry, not your febrile fantasies.

    2. simba says:

      So, you’re saying Burzyinsky kills people. Yeah, that seems in line with the evidence. Any hard evidence of statistically higher survival/cure rates than comparable treatment?

      “Cars kill more people every year than I do. Therefore, what I do is not wrong.”- the new defense for every serial killer, ever.

    3. David Gorski says:

      Oncologists are killing more people annually with chemotherapy and radiations than Burzinsky does. That’s a fact.

      You do realize, don’t you, that this post has nothing to do with Stanislaw Burzynski or antineoplastons. I’m not sure why you thought it was a good idea to post anything about Burzynski on this thread. I only alluded to him to point out that I wanted to switch topics and write about something different than what I’ve been writing about the last few weeks.

      1. Republicus says:

        Us whacks have to stick together, you know?

  8. goodnightirene says:

    I though T-Gel was a dandruff shampoo???

    1. windriven says:

      “I though T-Gel was a dandruff shampoo???”

      I thought it was one of those idiotic styling potions that make it look as if you haven’t washed your hair in the last few years. Vicks Vaporub but with more cachet and slightly better aroma.

      1. mousethatroared says:

        @Windriven – What could smell better than Vicks? (I suspect I am reincarnated from a koala bear.)

        1. windriven says:

          “What could smell better than Vicks?”

          That would be … pretty much everything. Unless you work for the ME. Then it would smell pretty good.

        2. Lytrigian says:

          Vicks smells good for the associations, not because it actually has an attractive scent. It unfailingly evokes childhood memories of Mom taking care of me when I was sick.

          Fortunately I remember more her love and caring than her actual methods, which involved not only rubbing Vicks on my chest but dabbing a bit right into my nostrils. That was… a little much, frankly.

          1. Interrobang says:

            Funny, the only associations I have with the smell of eucalyptus is of being sick. I don’t actually recall my mom ever rubbing that stuff on me, anyway; she made me do it. Not only that, but it smells foul anyway.

            /me is definitely not closely related to a koala

  9. stanmrak says:

    Unfortunately, this isn’t an unusual phenomenon today. Most medicine today is a triumph of marketing over science, since the entities marketing the product also have control over the science. Positive research gets published, negative outcomes get buried, since the journals are also controlled by their advertisers. What appears to be ‘peer-reviewed’ science is often just science manipulated for maximum profit, not public good.

    1. Harriet Hall says:

      “Most medicine today is a triumph of marketing over science”
      Most alternative medicine is a triumph of marketing over science; but that’s demonstrably not true for mainstream medicine, since there is no marketing for so many of the things we do, like surgery for appendicitis; and since we do so many things that are not good for marketers, like changing the guidelines for ear infections and sinusitis to reduce the number of antibiotic prescriptions.

    2. windriven says:

      stanmrak waxing philosophic on the debasement of science??? That is hilarious!

      I won’t bother to reiterate what Dr. Hall already handled nicely. I’ll just add that ‘peer-reviewed’ science at its most debased stands orders of magnitude above the superstition and anecdote that fluffs out your fantasies.

      Stand back and behold the sweep of medicine across the face of humanity over the last hundred years. Compare and contrast with the zero contributions of sCAMmery. Then crawl back under your bridge and whimper about the deficiencies of science.

  10. The frustrating thing about this for me, as a transgender man, is I can’t remotely get my insurance company to cover testosterone for me, but my husband was just offered this “treatment” fully covered because his T values were on the low side of the normal scale. Not even below the 300 cut off. We are soooo middle aged that his values should be a given.

    1. windriven says:

      I wonder if the new requirements of ACA will solve your issue?

  11. oldmanjenkins says:

    I guess we humans just have a problem with aging, or better yet, accepting that as we get older and we can’t do the things we did when we were younger. The pathologizing of aging is a farce. We get old and die. That is what all living things do. As we get older, our propensity of morbidity increases. For those with predispositions, this is accelerated. A 70 year old should not be doing what they were doing when they where 20, they could prematurely end their lives. Hair loss, Low T, the list goes on. If you can’t embrace this fact you will never be happy. I look 10 years older than my stated age, has always been the case (other than when I was born, I don’t think I looked 10). I embrace this, internalize it, process it and move on. We should focus on what we can do with the time we have and not waste energy trying to “extend” our lives anymore than we can. The years we extend are at the end of life and not in the middle. These usually aren’t the “golden years” that are advertised. Our bodies evolved to have certain levels of hormones at particular periods of time. Arbitrarily increasing these levels to when we were younger has numerous unintended consequences. At best these “practitioners” who run aging clinics can only say “I have your level higher than it was before.” What that means to the patient the “practitioner” couldn’t tell them. Testosterone is not simply a level as stated in the post.

    1. rork says:

      Danger. Naturalistic fallacy approaching.

      If added T could make my muscles bigger and stronger, my junk work better, and my desire (I mean other than libido) better, without any down side, I might try it.
      It’s the down side that’s the trouble. Make that question #5. (And that the up side is not that much of a winning.)

      I’m also saying that what the distribution of T levels are in the population of any age is not all that interesting.

      I’ve heard it called T in labs starting at least 25 years ago. I heard it from folks transitioning too. “Have you started T?” is a little more discrete.

    2. Lytrigian says:

      Wanting to feel younger is all about trying to make the most out of the time you have left. Who the hell wants to live through years and years feeling too tired to even care that you can’t do half the things that used to be fun for you? If there was a magic pill that could make that go away with no dangerous down-side, I’d take it in a second. A pity that Synthroid doesn’t quite manage that for me. Best it can do is make me somewhat less tired. (My T that’s low is thyroid, not testosterone.)

      Accept that I someday won’t be able to do the things I enjoy? Maybe. Embrace it? Never. I despise the very idea and always will.

      And don’t tell my one uncle he shouldn’t be doing things young men do. He took up skydiving in his retirement. Now that he’s well over 80 I THINK he’s given it up, but he wasn’t happy to do it.

      1. oldmajenkins says:

        Let me clarify when I say embrace it I mean accept that it is a part of the aging process. By embrace it I do not mean to infer happiness to the fact that one cannot do things they used to, or have a higher propensity for disease. But trying to chemically deny it with no regard for unintended consequences as these aging clinics do is irresponsible.

        If someone has fatigue that is significant enough to interfere with their quality of life there may be an underlying organic cause. That person needs to be seen by a SBM generalist to determine what (if any) is the underlying cause. I am not simply going to “go gentle into that good night.” I am exercising, eating a balanced diet, trying as best I can to control my stress, getting enough sleep, and seeing my SBM PCP to ensure my body is (as best it can) keeping up with my mind. But for someone (not saying this was stated implicitly or explicitly by any poster) that they should by default have the same energy level in their 70′s as they did when they were in their 20-30′s, this is just magical thinking.

        I used to enjoy soccer. Secondary to bi-lateral severe Osgood-Schlatter, and a reconstructive knee surgery I know longer enjoy it as I used to (as a participant). And whilst it is great your uncle did sky diving at age 80 (one thing I will never do at any age. I have a problem with heights) I am quite certain there are things he no longer does or has modified how he does them.

        Age in this country (IMO) is seen as a disease in and of itself. It is in actuality the natural progression of things. We grow, we age, we die. This is very much and oversimplification of the process and is in no way a nihilistic philosophy. It just is what it is.

  12. agedoc says:

    The widespread paranoia and mistrust regarding this issue is more a statement of the paranoia and distrust of PHARMA than of any real medical or scientific basis. The fact of the matter is there are far more studies (about 3 or 4 to 1)showing the benefits of treating low testosterone in aging men than vice-versa. Moreover, nowhere in this anti-testosterone flurry is it noted that ‘standard normal’ laboratory values are averages derived from all patients who get their levels drawn…included the very ill, infirm, and elderly. This artificially skews the ‘normal levels’ downward…meaning actual normal levels in healthy males should most likely be even higher than we think. This quote seems very appropriate here:

    “all truth passes through 3 stages. First it is ridiculed. Second, it is violently opposed. Third it is accepted as being self-evident”

    -Arthur Schopenhauer

    1. David Gorski says:

      You do realize, don’t you, that Schopenhauer almost certainly never said that. For instance, it’s not listed among “25 great quotes” of his.

      Besides its almost certainly never having been said by Schopenhauer, I hate this quote with a bloody passion. Actually, that’s not quite true. Rather, I find the quote rather amusing in a pathetic sort of way, first because it’s easy to demonstrate that it’s not true. For instance, in science Albert Einstein’s Theory of Relativity wasn’t exactly “violently opposed,” and a lot of other scientific findings that challenge the existing paradigm have been embraced. The second reason is because when people invoke Schopenhauer the implication behind their parroting the above quote is that they have The Truth. They then invoke the quote to argue that the reason that they are being ridiculed or opposed is that their “Truth” simply hasn’t made it to the “third stage” of Schopenhauer’s view of how Truth is accepted–but it will be! In other words, “They’ll see! I’ll show them! They thought me mad—mad, I tell you!—but I’ll show them!”

      Of course, what one must realize about this particular quote, a favorite of cranks and pseudoscientists the world over, is that it’s talking about truth. Non-”truth,” or pseudoscience/quackery, never makes it past the first or second stage–and rightly so, I might add. Yet those who invoke this quote seem to think that it is inevitable that their “truth” will make it to stage three. Don’t count on it.

      But, hey, I could be wrong. However, if I am, you didn’t provide me any evidence to start to question what I wrote. Some convincing, well-designed clinical studies showing that correcting “low T” in otherwise healthy men can do everything you and the other “T-men” say it can might do so. Give it a try.

      1. bluedevilRA says:

        I like to modify a quote from my favorite archaeologist, Henry Jones Jr. “Science is the search for fact–not truth. If it’s truth you’re looking for, Dr. Tyree’s philosophy class is right down the hall.”

    2. windriven says:

      “The fact of the matter is there are far more studies (about 3 or 4 to 1)showing the benefits of treating low testosterone in aging men than vice-versa.”

      I wonder if you’d be willing to cite the top 2 or 3 that you think are the most convincing?

      The consensus that I read in the literature suggests a very cautious approach to TST. NIH has funded a multicenter RCT (NCT00799617) that is slated to end in July 2015. Perhaps that will shed additional light.

      1. David Gorski says:

        Yes. Before the results of that study are published, I’m hard-pressed to recommend testosterone replacement therapy except in symptomatic, clear-cut, well-documented cases of hypogonadism using the criteria of the Endocrine Society (for example) and not the vague, airy criteria suggested by AbbVie and other sellers of TRT.

        Unless, of course, our “Schopenhauer”-quoting friend can provide high quality clinical trial data to show us that the benefits of TRT outweigh the risks for aging men.

        1. agedoc says:

          My my my…an interesting reaction by Dr Gorski whom it appears, is not a great fan of Schopenhauer. Dr. Gorski…your supercilious response to my relatively innocuous post is surprising, but maybe your irritability is due to low ‘T’….nonetheless I will offer you my response. First of all, when I stated that the literature is 4 or 5 to 1 showing the benefits of TRT, I was grossly understating the results of numerous observational and clinical studies. In fact, the new JAMA study you reference in your opinion article is the first and only study to demonstrate harm, and should therefore be interpreted carefully in light of all the other studies demonstrating beneficial results. Apparently, you are unfamiliar with the current clinical literature on testosterone therapy, so I will attempt to enlighten you. Current literature overwhelmingly supports low testosterone levels as being a lethal disease that is associated with heart disease, stroke, cancer, Alzheimer’s disease, and diabetes.
          The first set of references (download them here: http://sdrv.ms/IpNAMN ) are studies that review mortality in men treated with testosterone compared to control groups. The first set of studies show improved survival in testosterone treated men versus untreated men. There are fewer heart attacks, cancer, and reduced mortality in men treated with testosterone. Other studies go on to prove that low levels of testosterone increase morbidity and mortality in contrast to men with testosterone levels in the higher ranges. Moreover, low levels of testosterone are predictive of an increase in all-cause mortality (CAD, CVD, cancer). Other studies here show that there was no increased risk of cardiac events in men treated with testosterone.
          The second set of references (download them here: http://sdrv.ms/1b1mxhJ ) lists all the articles that demonstrate the physiologic benefits of testosterone administration on cholesterol, lipoproteins, insulin sensitivity, diabetes, inflammatory cytokines, endothelial dysfunction, atherosclerosis, blood pressure, memory loss, Alzheimer’s disease, mood, strength, energy, muscle mass, fat mass, osteoporosis, ED, sexual function, and all-cause mortality. What are the consequences of stopping or not taking it? Read the foregoing.
          The third set of references ( download them here: http://sdrv.ms/1iMQ4Dx ) reviews beneficial effects on quality of life as well as disease protection. The data on reduction of body fat, insulin levels, diabetes, inflammation, and vascular disease is truly amazing…. “Testosterone serves to maintain health in every system of the body.” Levels of testosterone in the low to mid-normal range are associated with an increase in illnesses as listed above.
          I hope this rather voluminous body of data serves to enlighten you…and if not I hope it serves to encourage you to do a thorough review of the literature before condemning a treatment that you know very little about.

          1. weing says:

            @agedoc,

            Aren’t you at all suspicious that all those studies show benefit and no harm? You don’t think we may be seeing the file-drawer effect in action? Those studies are almost too good to be true. Don’t get me wrong. I’d love to believe them. It reminds me of estrogen replacement therapy about 15-20 years ago. You know the saying “Once burned, twice shy.” I will echo Pete Townshend, “Won’t Get Fooled Again”

            1. David Gorski says:

              It’s because they’re cherry picked, of course. :-)

    3. Calli Arcale says:

      “all truth passes through 3 stages. First it is ridiculed. Second, it is violently opposed. Third it is accepted as being self-evident”

      Whether Schopenhauer really said this or not, I’d like to respond with a quote from Michael Shermer:

      “They laughed at Copernicus. They laughed at the Wright brothers. Yes, well, they also laughed at the Marx Brothers. Being laughed at does not mean you are right.”

      That’s the essential folly of the quote you attribute to Schopenhauer. It’s really a terrible argument to use when trying to support an idea.

      1. David Gorski says:

        Indeed. Nor does being “violently opposed” mean you are right. After all, wrong ideas are often “violently opposed” by reasonable people. Being “violently opposed” has little or no correlation with being right. If it has any correlation at all to being right, I’d be willing to bet that it’s probably a negative correlation.

        1. Calli Arcale says:

          The best way to take the quote is as motivation for the person attempting to prove an unconventional idea. Anybody bringing a new idea to the table has to expect it to be questioned and doubted, perhaps even vehemently so. (Look how long it took to reject the ether! The idea of lightspeed as a universal constant really was very counterintuitive.) That doesn’t mean you’re right; it means if you want to prove your idea, you’ve got to fight for it and work hard to answer all the questions and doubts and really *prove* the idea.

          So the quote is a good one for someone with a radical new concept to help motivate them to persevere. That is, however, the full extent of its usefulness. After all, while most great new ideas are ridiculed, most ideas that are ridiculed are actually wrong.

      2. Jake Hamby says:

        If Michael Shermer said that, he stole the quote from Carl Sagan, slightly modified. Sagan’s version is “They laughed at Columbus, they laughed at Fulton, they laughed at the Wright Brothers. But they also laughed at Bozo the Clown.”

  13. agedoc says:

    My my my…an interesting reaction by Dr Gorski whom it appears, is not a great fan of Schopenhauer. Dr. Gorski…your supercilious response to my relatively innocuous post is surprising, but maybe your irritability is due to low ‘T’….nonetheless I will offer you my response. First of all, when I stated that the literature is 4 or 5 to 1 showing the benefits of TRT, I was grossly understating the results of numerous observational and clinical studies. In fact, the new JAMA study you reference in your opinion article is the first and only study to demonstrate harm, and should therefore be interpreted carefully in light of all the other studies demonstrating beneficial results. Apparently, you are unfamiliar with the current clinical literature on testosterone therapy, so I will attempt to enlighten you. Current literature overwhelmingly supports low testosterone levels as being a lethal disease that is associated with heart disease, stroke, cancer, Alzheimer’s disease, and diabetes.
    The first set of references (download them here: http://sdrv.ms/IpNAMN ) are studies that review mortality in men treated with testosterone compared to control groups. The first set of studies show improved survival in testosterone treated men versus untreated men. There are fewer heart attacks, cancer, and reduced mortality in men treated with testosterone. Other studies go on to prove that low levels of testosterone increase morbidity and mortality in contrast to men with testosterone levels in the higher ranges. Moreover, low levels of testosterone are predictive of an increase in all-cause mortality (CAD, CVD, cancer). Other studies here show that there was no increased risk of cardiac events in men treated with testosterone.
    The second set of references (download them here: http://sdrv.ms/1b1mxhJ ) lists all the articles that demonstrate the physiologic benefits of testosterone administration on cholesterol, lipoproteins, insulin sensitivity, diabetes, inflammatory cytokines, endothelial dysfunction, atherosclerosis, blood pressure, memory loss, Alzheimer’s disease, mood, strength, energy, muscle mass, fat mass, osteoporosis, ED, sexual function, and all-cause mortality. What are the consequences of stopping or not taking it? Read the foregoing.
    The third set of references ( download them here: http://sdrv.ms/1iMQ4Dx ) reviews beneficial effects on quality of life as well as disease protection. The data on reduction of body fat, insulin levels, diabetes, inflammation, and vascular disease is truly amazing…. “Testosterone serves to maintain health in every system of the body.” Levels of testosterone in the low to mid-normal range are associated with an increase in illnesses as listed above.
    I hope this rather voluminous body of data serves to enlighten you…and if not I hope it serves to encourage you to do a thorough review of the literature before condemning a treatment that you know very little about.

    1. David Gorski says:

      My my my…an interesting reaction by Dr Gorski whom it appears, is not a great fan of Schopenhauer. Dr. Gorski

      Not quite, but nice try. The correct way to put it is that I’m not a fan of that particular quote frequently attributed to Schopenhauer, which almost certainly was falsely attributed to Schopenhauer. The reason I’m not a fan is because it is a patently dumb quote, so much so that I hope Schopenhauer didn’t say it. Fortunately, he almost certainly did not.

      As for a thorough review of the literature, one notices that you have cherry picked articles that support your point of view and ignored the once that don’t, such as the ones I cited. There’s also the Endocrine Society guidelines, which are far more conservative. Even several of the references you included don’t really support extensive testosterone administration in older men with mildly low testosterone, as the conclusion is an association but no evidence of causation; i.e., it’s not clear whether lower testosterone is a consequence of the disease attributed to it or potentially causative. Correlation does not necessarily mean causation, and if it doesn’t then supplementation is unlikely to correct the underlying pathophysiology.

  14. PDelaney says:

    When I moved into a new practice a few years back I noticed a lot of men on testosterone replacement of one sort or another. A little research turned up a clue as to why…in obese men total testosterone goes down, though the free (and the metabolically important part) remains normal. Something about adipose tissue hormones changing testosterone binding protein levels.

    So after discussing this with them, I discontinued testosterone on many obese men (some in their 20′s weighing over 400 lbs). Then checked free testosterone levels and found those levels to be normal with low total T….and no change in the symptoms once the T had been stopped.

  15. davdoodles says:

    “Testosterone serves to maintain health in every system of the body.”

    Boilerplate marketing gibberish.

    If, as it appears you intended it to be, a quote from the “voluminous data” you linked to, it’s little wonder the medical scientific (as distinct from the marketing) community remains unimpressed.

    Basically, you can link to all the glib and bumph you like. But the reality is the medical consensus does not support testosterone-as-miracle-elixir-for-all-the-body’s-systems theory, because there is no sufficiently convincing, replicated, science to support it.

    You imply that the medical scientific community is closed-minded and/or lack the requisite knowledge. Anti-Schopenhauers, as it were. But that is the wrong way to look at it. A better way to understand how to affect the medical consensus is to imagine the medical scientific community not as some malevolent, disagreeable or narrow-minded force out to first-ridicule-you, but rather to imagine it as a gigantic ATM.

    A mere mechanism. Utterly implacable, unless and until you push the correct little buttons in the correct order. Then, out pours the love.

    Put bluntly, you can call Dr Gorski and the rest of the medical scientific community all sorts of names, and ascribe to him and them all manner of blinkered and clandestine motivations. But Honey Badger don’t give a sh*t.

    Do. The. Science. There is no substitute.

    1. Lawrence says:

      Another example of taking something that is good for extreme conditions & back-filling “the Science” to try to make it applicable for anyone who might even have a hint of such a “condition.”

      Classic move for marketing, but bad for Science overall….

  16. windriven says:

    @agedoc

    You’ve compiled an interesting list. I’ve only been through the first set and I haven’t looked for work challenging these results yet. But I have many of the same concerns voiced by Gorski, weing, et al.

    First is that testosterone levels vary considerably in the same individual yet all the studies seem to use fixed bars of 250 or 300. Measured how many times? Weighted and averaged how? Is there a consensus regarding diagnosis of hypotestosteronemia by blood tests alone? Or does a more complete diagnosis look deeper?

    Second is that the Endocrine Society does not seem to embrace broad use of TRT. First, do no harm. Your studies show fairly impressive cardiovascular benefits. But what lies on the other side of the coin? More importantly, how much confidence do we have that we completely understand what lies on the other side of the coin?

    Third, your zeal in promoting testosterone as the one true cure for lots that affects older men is unsettling, sounding overmuch like the wild promises of a chiropractor. Your selection of literature suggests cautious optimism, nothing more.

    Finally, the question left unanswered is: why do these men have testosterone levels so low that it impinges on their daily activities? Why do others continue to live active, happy lives without supplemental testosterone? Is TRT simply masking a more fundamental problem?

    1. agedoc says:

      Gorski you are a piece of work…first you ask me to provide you with evidence, and when I do what you ask, you say the evidence is ‘cherry-picked’ . Duh…of course its cherry picked! you asked me to do that when you asked for studies that support my point of view! More importantly though, you discuss two or three studies in your article that support your point of view, and you conveniently left out all the studies that don’t. Isn’t that the same thing you are accusing me of doing? Or is it OK for you to do it, because you are fighting the good fight against big bad Pharma?

      Science is the process of confirming or refuting hypotheses based upon studies. These studies can be observational, experimental, placebo-controlled, correlative,, or meta-analyses of the literature. In medicine we do not have the luxury of being able to control all variables as can be done in a laboratory, so instead we have to rely on the consensus derived from all available studies. I have dropped no less than 27 studies in your lap that support my assertions. You, on the other hand, have given me 2 or 3 and have conveniently left out the 27 studies that do not support your point of view from your article and apparently feel justified in dismissing them all as ‘cherry-picked’. Certainly you….an outspoken proponent of science and evidence-based medicine can see the irony in ignoring overwhelming evidence that is contrary to your opinion? or maybe not….either way I have neither the time nor the desire to waste my time debating with someone who does not want to even consider that he may be wrong.
      As for me I will continue to treat my patients based upon the existing evidence for TRT, and enjoy their thanks when they can have regular sex again, slim down, have energy to exercise and live their lives to the fullest. I leave you guys to trumpet your special brand of evidence-based medicine…only if the evidence supports your point of view of course.

      Since you love quotes, I have a final one for you:

      “Go on until you get to the end…then stop”

      -Lewis Carroll, Alice in Wonderland

      1. David Gorski says:

        More importantly though, you discuss two or three studies in your article that support your point of view, and you conveniently left out all the studies that don’t.

        Uh, no. while I did cite some studies supporting no benefit for TRT, I also cited review articles that look at all the evidence and evidence-based guidelines from the Endocrine Society, which, BTW, would have a financial interest if more men were evaluated for “Low T,” because a lot of those men would probably be referred to an endocrinologist and/or urologist.

        I am, however, amused by your attempt to claim that numbers of studies are so important, as if whoever can cite the most studies wins. It doesn’t work that way. Quality matters more than quantity, and the studies you cited just aren’t the greatest quality. In fact, that’s the problem. The studies available are uniformly of mediocre to poor quality. We usually don’t make sweeping recommendations about something like recommending TRT for millions of men with supposed “Low T” in the absence of much better science. To cite an example of why quantity doesn’t trump quality, I like to use acupuncture studies. There are lots and lots of studies out there that purport to show a benefit from acupuncture for all sorts of conditions. However, the higher the quality the study, the less likely a benefit above placebo will be found.

        Believe it or not, I remain agnostic on the question of TRT except for one thing: Right here, right now, marketing has won over science. If clinical trials validate the use of TRT for some of the conditions for which it is now advertised, I will change my mind, as I have done with a number of clinical treatments. My position now, however, must remain that, lacking evidence, it makes no sense to be so aggressive in recommending testosterone for any older man whose testosterone levels fall below the normal range of that of a young man. It is also clear that there is no high quality evidence that “Low T” is associated with all the conditions claimed for it or that supplementing “Low T” corrects the conditions claimed for it.

        Finally, it really does amuse me even more that you seem to think my judgment is clouded by hatred of pharma, given how often I’m accused of being a “pharma shill” by alt-med mavens or attacked by concern trolls complaining that we at SBM write so much about CAM but don’t take on the depredations of pharmaceutical companies.

    2. agedoc says:

      “your zeal in promoting testosterone as the one true cure for lots that affects older men is unsettling”

      I don’t know where you got this from…I would never promote anything as the one true cure. That is quackery. My goal here was to introduce another point of view, and one that is supported by the vast majority of the literature. I never expected the authors quite ridiculous response though. Oh and Mea Culpa about the quote I used…Gorski seems to have the time to research Schopenhauer. I propose he use the time to review the literature about TRT instead.

      1. David Gorski says:

        My goal here was to introduce another point of view, and one that is supported by the vast majority of the literature.

        Except that it’s really not.

        Oh and Mea Culpa about the quote I used…Gorski seems to have the time to research Schopenhauer.

        “Researching” that Schopenhauer quote involved coming across a couple of posts three or four years ago, quite by accident, that demonstrated that Schopenhauer almost certainly never said what you quoted him as saying and then saving the links for future use. I will say that there’s no shame in your being fooled by that quote, as lots of people think Schopenhauer said that. There is shame, however, in parroting the intellectually vacuous and transparently false sentiment embodied in that quote. Here’s hoping you learned your lesson and don’t use it any more.

      2. windriven says:

        @agedoc

        “I don’t know where you got this from”

        That may have been an overstatement of your position and if it is I apologize. But you do seem to be ahead of the endocrinology establishment in your advocacy for TRT.

        I plan to spend some time over the holiday weekend reviewing the rest of the citations you offered – not that it matters a bit. I am not a physician and, to the best of my knowledge I do not have a ‘T’ problem though as years slip by it becomes harder to maintain my ideal weight despite a very active lifestyle. Still, and speaking now only for myself, I would be loath to embark on TRT for something as trivial as weight maintenance. There’s always the option of putting down the fork ;-)

        At the same time I understand men who have physical or sexual performance issues aggressively pursuing solutions. But then that brings us back to the guys with radio ads and ‘seminars’ promoting TRT and that, in my opinion, is never good medicine.

  17. Rob Cordes, D.O. says:

    What concerns me as a pediatrician is an unnecessary availible testosterone product on the market. Will a black market be created for high school athletes who want to use it?

    1. windriven says:

      Sadly, that market already exists.

      Every young athlete should be forced to look at the picture of Lyle Alzedo on the cover of SI (around 90 or 91 I think). If you don’t know, Alzedo was an aggressive Oakland DB who used steroids and who came to blame his ultimately fatal brain cancer on that use. I don’t know if the ca and the steroids were related but it is a sobering story nonetheless.

      1. RobCordes, DO says:

        I know of no evidence Alzedo’s tumor was related to his anabolic steroid abuse. The potential problem in using it is in sounding like Reefer Madness.

        1. windriven says:

          You’re right about Reefer Madness I suppose.

          For what it is worth, I didn’t claim that the cancer and steroid use were related – Alzedo made the claim.

          1. windriven says:

            The SI cover is nonetheless a powerful image. Reefer Madness? Maybe. But if it kept 1% of high school athletes attracted to steroids from using them it would be worth it.

  18. DJDenning says:

    As a part of our Formulary, we recently included the Endocrine Society guidelines in response to physicians who were much too generous with the testosterone in our methadone maintenance patients. While it’s true that methadone can cause hypogonadism, our patients are primarily young guys, and many of them are trying to bulk up. I’m not convinced that testosterone supplementation in methadone maintenance patients is treating the lab value rather than the patient in many cases.

  19. Nick says:

    Thank you for the post. I’m curious how you think about low ‘free testosterone’ versus the serum total? Free can measure low even when serum measure within the recommended range. Do your research address this type of situation?

    Thank you.

    1. agedoc says:

      Hi Nick-

      When administering TRT, the best lab value to use is free testosterone, since that is the active moiety i.e. the total testosterone represents the sum of the free and bound testosterone with bound testosterone not used by the body (it is bound to albumin and SHBG–sex-hormone binding globulin). The other thing to keep in mind is that levels of testosterone (and any hormone for that matter) should be ordered using LCMS (Liquid Chromatography Mass Spectrometry) method of analysis. Most labs have this as an option. It is more expensive, but is the most sensitive test there is to measure hormone levels. In my practice, I always try to raise testosterone levels first by stimulating endogenous testosterone production by the Leydig cells in the testicles…since that is the least invasive method and the most ‘natural’. I use HCG for this and it works very well..if necessary after a few months I add exogenous testosterone although In younger men HCG alone is often adequate to maintain testosterone levels and it does not produce testicular atrophy like exogenous testosterone can. HCG works because molecularly it is very similar to LH, and ‘fools’ the body into thinking more LH is being released. As a consequence, and the testicles pump up testosterone production in response. Also, when I administer exogenous testosterone for patients I prefer testosterone cypionate since the pharmacology is more predictable and more reliable than the various transdermal creams and gels that are available.

  20. Heather A. says:

    I think the latest advice from FDA on disease-awareness advertising is draft guidance from 2004. And nowhere does it say — kind of naively, actually — “Don’t invent diseases.” Even unbranded communications are supposed to be supported by actual, you know, scientific evidence, but if FDA says it won’t regulate them, then who will?

    In theory, a pharma’s medical reviewers are supposed to shoot down any marketing claims not supported by evidence, but that’s still pretty fox-guarding-the-henhouse-y.

  21. Dave says:

    warning, anecdotal post but might bring some needed levity here.

    About 30 years ago, in the pre-viagra world, I had a patient we saw occasionally. Once he was admitted for a stroke, which he recovered from well. Then he was admitted in hypovolemic shock from a massive GI bleed due to a duodenal ulcer. After a harrowing few weeks, multiple transfusionand oversewing of his ulcer he did ok and was discharged.

    A year later he came into the office complaining of impotence. At that time there usually was little we could do about this but I ordered a prolactin and testosterone level and a few other studies, and surprisingly his testosterone level was quite low. We started him on testosterone injections, as there were no gels back then.

    2 weeks later he came to the office, enthusiastically pumped my hand up and down and told me I was the best doctor in the history of medicine.

    A week after that his nephew came in inquiring if he could get some of the “monkey juice” we gave his uncle.

    Note we didn’t get a similar response when we pulled him through his life threatening bleed. It interesting what’s important to people.

    I still smile when I think about this. In no way is this post a comment on the “low-T” stuff today.

    1. Harriet Hall says:

      That reminds me of the goat gland charlatan http://www.sciencebasedmedicine.org/charlatan-quackery-then-and-now/ He got wonderful responses from his patients too, only he wasn’t doing anything that could have a real effect.

      1. Dave says:

        Perhaps, but I think he had hypogonadism and had a physiologic response to replacement.

        1. Harriet Hall says:

          I wasn’t questioning your patient’s response. Just pointing out a similarity between pharmaceutical “monkey juice” and quack goat glands.

  22. Mark Rupertson says:

    Thanks for this article. The best thing to do here is to consult to a specialist so that they will know what proper procedure to be done. It is much safer and more reliable than taking immediately any endorsed supplement/drug on the market. health wise and money wise.

Comments are closed.