Why are Doctors Ignoring Testosterone Replace Therapy?

There have been quite a number of studies recently showing that, not only is testosterone replacement therapy (TRT) very safe, but it also brings with it many additional benefits beyond boosting libido and reducing erectile dysfunction. These add-on benefits, as it were, are only now beginning to emerge from the medical literature and they are very interesting. They would include:
• A reduction of Type 2 Diabetes. Reduced insulin requirement.
• Reduction of serum lipids and a decrease in the incidence coronary artery disease.
• A reduction of mortality arising from the Metabolic Syndrome.

No matter how you do your sums, these are fairly spectacular benefits to accrue from one simple and now known to be a safe line of therapy. And yet very surprisingly the majority of doctors continue to ignore TRT for older men. In doing so I would contend that they are denying their older male patients a better quality of life and a lower risk of early death. That is a very serious charge indeed.

So why is this I wonder? As a doctor I make no apologies for the behaviour of my colleagues. In fact, to be perfectly honest with you, I believe that doctors ignoring TRT is an indictment against the profession. This may well prove to be so in time. Nonetheless, I would offer the following observations to explain why doctors are not using TRT. Each is erroneous of course and I will explain why as we go along:

1. The results of the Women’s Health Initiative study into the safety of HRT for postmenopausal women were published in 2002. This sent shock waves through the medical profession. It showed an increased risk of breast cancer and heart disease among those women on combined hormonal replacement therapy as distinct from those not on any such treatment. The increase for cancer was of the order of eight extra cases per 10,000 women on HRT.
Fallacy: You simply can not extrapolate anything from this important study and apply it to testosterone replacement therapy for men. To do so would be utterly illogical. And yet I believe that at some subliminal level that is what’s happening. All hormonal replacement therapy is now being tarred with the same brush, if only at some illogical subconscious level.
2. Another misconception warmly embraced by many doctors is that ageing is natural and the negative consequences of ageing, such as the loss of libido and erectile dysfunction, are best not interfered with. There are prejudices at work here of course. These very same doctors would never shrink from aggressively treating hypertension or osteoarthritis in men, no matter what age they are. But ask them to consider the older man’s sexual life and all sorts of objections will be thrown up.
Fallacy: There are far more benefits for the older man on TRT than mere libido boosting or improved sexual function. Recent studies have clearly indicated that this safe treatment carries many additional advantages. Not least of these is a reduction in early mortality arising from the Metabolic Syndrome.
3. Finally then of course there is the greatest mistaken belief of them all, the implacable one that’s almost impossible to shift. I refer of course to the erroneous notion that raised testosterone levels can lead to an increased incidence of prostate cancer. The fact that prostate cancer is a disease of older men with depressed testosterone levels and seldom found in younger men with raised testosterone seems not to matter at all. No, no. Raised testosterone levels increase the risk of prostate cancer and that’s that.

Fallacy: The geneses of this illogical belief are not difficult to find. The first line of treatment for men with metastatic prostate cancer is to wipe out all their testosterone with a drug called Finasteride. This will give the patient at least some temporary respite and his cancer will abate. So the argument goes; if zero levels of testosterone are curative for prostate cancer then it must follow that raised levels must be causative. But this is neither logical nor scientific. The fact that the absence of something is curative does not mean that its presence is causative. To so reason is to use what’s known as a corollary. Corollaries may have some place in religious debate and mathematics but they have no place in medical science and my wish is that doctors would stop using them.
Then the final nail in the coffin of this pishogue about testosterone causing cancer came along. A recently conducted study into the safety of testosterone replacement therapy, carried out by M.R. Feneley and M. Carruthers at The Institute of Urology and Nephrology University College, London and you don’t get much grander than that; concluded thus as follows:

The incidence of prostate cancer in this group of men (1,500) treated with testosterone over many years was equivalent to that expected in the general population.

Now, do you think that that will sway many doctors into taking a more positive view of TRT?
Not at all. You must be joking. Old prejudices die hard.