Treating Men with Testosterone Deficiency can be Challenging

Statue of Abraham Lincoln at the Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)
Statue of Abraham Lincoln at the Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)

Testicles produce a hormone called testosterone that plays an important role in the masculine growth and development during puberty. Testosterone also plays an important role in the production of sperms. Poor testicular function results in erectile dysfunction (impotence). There is a failure to get and maintain an erection firm enough for sex.

Testosterone deficiency syndrome (i.e. poor testicular function) affects approximately 40 per cent of men aged 45 or older, although less than five per cent of these men are actually diagnosed and treated for the condition. It may affect multiple organ systems and can result in substantial health consequences for men.

Despite some controversy, testosterone therapy has been established as a safe and effective principal treatment for poor testicular function for nearly 70 years. But there is no consensus among experts on how and when to treat men with this condition.

A recent article in the Canadian Medical Association Journal (CMAJ December 8, 2015) welcomes the new Canadian guideline from the Canadian Men’s Health Foundation. It is hoped that the new guideline will clarify the management of this condition in the light of the huge volume of research on this topic over the last five years.

In the past there have been multiple guidelines from different groups like European Association of Urology, the International Society for Sexual Medicine, the International Society for the Study of the Aging Male (2008), and the Endocrine Society guidelines of 2010.

One cannot treat a condition if it is difficult to make a diagnosis. The diagnosis of testosterone deficiency syndrome is not straightforward, says the CMAJ article. The reasons are several. There are limitations to testosterone measurement and there is lack of a valid symptom score. This makes it difficult for the primary care physicians to make a diagnosis and start treatment. Especially when the experts cannot agree on values (normal vs. abnormal blood levels of testosterone).

The new guidelines do not define normal/abnormal blood levels for making a diagnosis of testosterone deficiency syndrome. Instead, the authors put weight on a combination of factors – clinical history, physical examination and response to therapy – in making the diagnosis, in addition to measuring testosterone level.

The European Association of Urology and the International Society for Sexual Medicine set parameters that men with a total testosterone level of less than 8 nmol/L will usually benefit from treatment. A trial of therapy may be indicated for those with levels between eight and 12 nmol/L in the presence of substantial symptoms.

There is no consensus on how long the initial trial of testosterone should last. The Canadian guideline advises a three-month trial of treatment. Some experts disagree with that. They suggest the trial should last six-months to 12-months.

Some other points of interest:

  • More than three-quarters of men with type 2 diabetes have erectile dysfunction, and about 90 per cent have positive symptom scores for testosterone deficiency syndrome.
  • Injection of testosterone, especially long-acting formulations, has higher efficacy rates and safety benefits than topical treatment. Other options are gels, patches or oral pills.
  • Opinion varies on monitoring patients taking testosterone therapy e.g. checking effects of testosterone on prostate (PSA).

It is important to remember that many important clinical issues remain unresolved. This article is just a summary of important points. The reader is advised to consult with his physician for more information.

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