Low Testosterone

Older men whose testosterone levels have dropped over the years should only be given testosterone replacement to treat sexual dysfunction, according to new guidelines from the American College of Physicians (ACP). "Physicians are often asked by patients about ‘low T’ and are skeptical about the benefits of testosterone treatment," said Robert McLean, MD, MACP, president of the ACP.  The analysis showed that older men might sustain small improvements in sexual function with testosterone treatment but are unlikely to experience improvement in energy, mood, or cognition.

Sales of treatments for low testosterone or "low T" tripled from 2001 to 2011, fueled by direct-to-consumer advertising promising that androgen replacement therapy, testosterone in the form of skin patches, topical gels, pills and shots, could restore men's vitality and libido. That trend reversed starting in 2013 as studies were published suggesting the treatments carried the risk of stroke and heart attack. In 2016, the U.S. Food and Drug Administration ordered manufacturers to list warnings of the risk for heart-related and mental health side effects on product labels.

To refine the potential benefits and harms of testosterone therapy in men with age-related low testosterone levels, the ACP has issued a set of recommendations, published in the Annals of Internal Medicine. The guidelines are based on a review of evidence from 38 randomized controlled trials between 1980 and 2019 that evaluated the effects of testosterone therapy on various outcome measures. These measures include quality of life, sexual and physical function, and adverse events among older men with low testosterone levels.

The primary guideline is a suggestion that clinicians should start a discussion about whether to initiate treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function. This discussion between clinician and patient should include potential benefits, harms, costs, and patient preferences. The rationale for the guideline is based on evidence indicating patients may see small improvement in sexual functioning with treatment but little evidence for improvement of physical function, depressive symptoms, energy, or cognition. 

The new study also suggested that clinicians should be reevaluating symptoms within 12 months and periodically thereafter. Treatment should be discontinued by clinicians in men with age-related low testosterone with sexual dysfunction who see no improvement in sexual function. The conclusive recommendation suggests clinicians should only prescribe testosterone treatment in men with age-related low testosterone for treating sexual function issues and not initiate treatment to improve energy, vitality, physical function, or cognition.

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