Alexander W. Pastuszak, MD, PhD - INTERVIEW

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ALEXANDER PASTUSZAK: So, I think that there’s a significant issue with the reference ranges that labs put out, because they vary between labs, and how patients are actually treated. Part of this issue is the lack of understanding that hypogonadism is both a low testosterone level, and in that case, following the guideline or merging that with the presence of symptoms, is the way that I treat my patients; meaning if a man comes in who has what would be considered a normal testosterone level, so above the threshold of normal based on the reference lab or even slightly above the threshold of normal based on guidelines, but that patient still has symptoms of low testosterone, I would treat that person.

So, with regards to thresholds for hypogonadism by the number--so, a testosterone threshold of 300 or 250 or above 300—so, I think that we don’t yet have enough data, especially across all ages to be able to definitively say that one number is a threshold that needs to be followed. So, when I treat my patients, I treat them based on the presence of their symptoms, as well as what their levels show. And if they’re not strictly below a certain number, if they come in with symptoms of low testosterone, they’ll still likely get treated.

So, we noticed through experience and also just knowing that there are really not age-specific testosterone levels, that younger men tended to develop hypogonadal symptoms at higher testosterone levels. So, when we studied this, we found that, in fact, younger men were coming in—so, men less than 40 were coming in—with symptoms at a higher testosterone level than what would normally be considered--or by the guidelines or by laboratory thresholds—be considered hypogonadal. So, we do think that at least in younger men, they have a higher threshold or a higher number at which they will develop hypogonadal symptoms and merit treatment.

So, urologic practices vary quite a bit in subspecialties such as ours—men’s health, low testosterone, sexual dysfunction and fertility. We see a lot of men coming in for specific symptoms such as erectile dysfunction, hypogonadal symptoms, other testicular issues. In these men, we screen them for diabetes—you know, either by asking them questions or even by testing for hemoglobin A1C or glucose tolerance—and in these men, we routinely get testosterone levels. I mean, it’s very well-known at this point that testicular function is significantly affected in men with diabetes. Glucose homeostasis is up – it results – or lack of glucose homeostasis results in testicular dysfunction in these types of men. So, we certainly do follow that and treat – test and treat these men.

So, there are good emerging data now that men who are obese and who have diabetes will, by and large, have low testosterone. So, those are the types of men who even regardless of whether they have symptoms, should be tested for low testosterone.

So, to the physicians out there who treat men or who would consider treating men for hypogonadism with testosterone, there are good data now that support the safety of testosterone in effectively all categories of risk—so, cardiovascular risk, prostate cancer, BPH and LUTS. While they’re not definitive, I would encourage the physicians out there who are treating men with testosterone, to engage with their patients, to engage in shared decision making, and to make sure that their patients, as well as them, know the potential risks and how to mitigate them.

The question comes up very frequently from both patients and physicians what is the risk of prostate cancer progression, recurrence worsening in men on testosterone. You know, in 2018, we have pretty good data now, both in the lab as well as clinically, that show that the risk for prostate cancer progression or recurrence or worsening in any way is not really enhanced by giving them testosterone and normalizing their testosterone levels. In fact, we know that prostate cancer cells grow better at lower testosterone levels, at actually hypogonadal testosterone levels. And there’s a new type of therapy called bipolar androgen therapy where you can treat men with metastatic castrate-resistant prostate cancer—the worst type of prostate cancer—with testosterone, and have improvement in prostate cancer.

There’s been a lot of controversy about cardiovascular risk with – in the setting of testosterone therapy. And in 2018, we had the American Urological Association come out with a guideline which has really helped this to a large extent. And one of the main points that they make in that guideline is that men with low testosterone levels may actually be at increased cardiovascular risk. This is the first time we’re hearing this type of information from a professional society with regards to cardiovascular risk and testosterone. And there are good data now that show that clinically, men with low testosterone are at increased cardiovascular risk and increased mortality risk; and really no data that show that men who have normal testosterone levels are at any sort of increased cardiovascular risk.

There’s been a significant amount of concern about testosterone therapy making men’s BPH or lower urinary tract symptoms worse. And the latest data that come from both some work that our group has done, as well as the combined work of numerous studies over the years, actually show that giving men testosterone can make their urinary tract symptoms better, and can actually increase their bladder capacity. In a recent meta-analysis that we published, we actually showed that there was no difference in symptom change in men on testosterone versus men on placebo. So, these data taken together support really that there’s not a negative effect, and there may be a positive effect even, of testosterone therapy on voiding symptoms and BPH.


 

Speakers

Prof. Dr. med. Marija Pfeifer

Prof. Dr. med. Marija Pfeifer
Medical Faculty
University of Ljubljana,
Slovenia

Alexander W. Pastuszak, MD, PhD

Assistant Professor Center for Reproductive Medicine Division of Male Reproductive Medicine and Surgery Scott Department of Urology
Baylor College of medicine

 

Alexander W. Pastuszak, MD, PhD

Assistant Professor Center for Reproductive Medicine Division of Male Reproductive Medicine and Surgery Scott Department of Urology
Baylor College of medicine

 

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