Testosterone Therapy in Older Men with Late-Onset Hypogonadism: A Counter-Rationale
Basaria S. Endocr Pract. 2013 Sep 6:1-40. [Epub ahead of print]


Section on Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.


Objective: The past decade has seen a surge in the number of older men being referred to endocrinologists for consideration of testosterone therapy for late-onset hypogonadism (LOH) to treat symptoms such as fatigue, sexual dysfunction and decreased vitality. As a result, the prescription sales of testosterone have increased 20-fold, mainly due to a sophisticated marketing campaign by the industry and the failure of clinicians to distinguish organic hypogonadism from LOH. The objective of this review is to provide a counter-rationale of testosterone therapy in LOH.Methods: A retrospective review of seminal English-language epidemiologic studies and clinical trials related to testosterone and older men. Review articles and their references were also reviewed and included where relevant.Results: Population studies reporting on LOH have several shortcomings such as use of multiple numeric definitions, use of testosterone assays not considered standard and measurement of testosterone at a single time point. In contrast to the higher prevalence based solely on numeric values, the syndromic prevalence of LOH is only 2%. Although attrition of testicular Leydig cells and slowing of the GnRH neurons contribute to LOH, obesity and other co-morbidities strongly influence testosterone levels, suggesting that testosterone is a biomarker of health. Testosterone therapy in LOH has consistently shown improvement in muscle mass and strength, however, improvement in physical function is limited to a few trials. Similarly, efficacy of testosterone therapy on falls and fracture rates remain unknown. In terms of risks, erythrocytosis remains the most common adverse effect of testosterone therapy in older men while long-term risks on the prostate and cardiovascular system remain unclear.Conclusion: Considering the paucity of data on clinically meaningful outcomes, uncertain risks and the fact that modifiable risk factors adversely influence testosterone levels, healthy lifestyle and treatment of co-morbidities might attenuate age-related decline in testosterone levels.