To T or Not to T: Is That the Question?

Jerry Brainum

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“I don’t believe in andropause.” With those words, John’s doctor summarily dismissed John’s request for testosterone-replacement therapy (TRT). The word andropause refers to a drop in the primary male hormone, testosterone, as part of the aging process. Along with the drop in testosterone, which occurs at a rate of 1 to 2 percent per year, commencing at around age 40, comes a host of symptoms.

John based his request on a recent blood test, which showed a 316 testosterone level. While some doctors consider that a “low normal” level, it wasn’t from John’s point of view. The normal level of testosterone ranges from 300 to 1,000 nanograms per deciliter of blood, with younger men having higher levels. Since John was a lifelong bodybuilder, his low testosterone levels likely had something to do with his lack of gains in muscle size and strength in recent years.

John’s doctor warned him that using any form of testosterone was a “known stimulant of prostate cancer, as well as cardiovascular disease.” The doctor was echoing the opinion of many physicians. In their collective minds, male menopause, another term for andropause, just didn’t exist. Yet many of those same doctors still provided hormonal-replacement therapy (HRT) in the form of estrogens and progestins to women, ostensibly because of the established health benefits.

Many in the medical profession think that a gradual lowering of testosterone in men is simply an inevitable part of the aging process. Their concerns about the alleged dangers of TRT are usually based more on emotion than on science, such as the notion that TRT causes prostate cancer and promotes cardiovascular disease.

Another reason, of course, is the steroid stigma. While anabolic steroids, which are altered versions of testosterone, do have some valid medical uses, the negative publicity about rampant steroid abuse in sports has led many to conclude that the negatives outweigh any positives. Government pressure on physicians to avoid dispensing testosterone-related drugs also plays a role here.

Testosterone Deficiency: Real or Imagined?

Despite the continuing skepticism of many in the medical profession, the TRT prescription rate continues to rise. Studies show a 500 percent increase in the sale of testosterone-based drugs between 1993 and 2001, and that rate continues to grow. Numerous studies dispute the previously held dogma that TRT is dangerous to long-term health. Along with that, men are refusing to go gently into that good night, refusing to accept feebleness and lack of quality of life simply because their bodies are no longer making optimal amounts of a hormone that has flowed in their blood since birth.

When a man reaches middle age, an event occurs in his body that turns off testosterone. The event may initially occur in the brain, through a gradually diminished secretion of the gonadatropins that govern the release of luteinizing hormone, a pituitary gland agent that controls the synthesis of testosterone in the testes. Or it could happen in the testes themselves. In that case the testicular cells refuse to respond to LH’s prodding signal to kick up testosterone production.

A less commonly discussed cause of lower testosterone levels in men, particularly middle-aged men, is a gradual increase in bodyfat. Deep-lying fat in the abdomen, known as visceral fat, is linked to both insulin resistance and lower testosterone levels. Higher levels of belly fat lead to lower levels of sex-hormone-binding globulin, the protein-binding hormone of testosterone, in the blood. That, in turn, makes free testosterone circulating in the blood more susceptible to the actions of aromatase, an enzyme found in fat and other tissues that converts testosterone into estrogen. The increase in estrogen signals the hypothalamus in the brain to curtail the release of gonadotrophic hormones that dictate testosterone synthesis. The lack of testosterone leads to even greater fat deposition in the abdomen and under the skin, producing a vicious metabolic cycle that results in lower testosterone levels, along with a heightened risk of diabetes, high blood pressure, cardiovascular disease and the metabolic syndrome.