Importance of long-term testosterone treatment to achieve full benefits?

Description

Clinicians should actively look for testosterone deficiency in patients with:

  • Type 2 diabetes
  • Metabolic syndrome
  • Abdominal obesity
  • Erectile dysfunction (particularly in those who respond poorly to PDE5i treatment)
  • Unexplained tiredness
  • Older patients with unexplained fractures, osteoporosis or anemia
  • Patients with chronic disease
  • Opioid users

It is also important to address other issues, such as sleep apnea, weight reduction and lifestyle modification, that can increase endogenous testosterone levels.

Correcting testosterone deficiency confers multiple benefits:1,2

  • Reduced mortality risk
  • Improved sexual function
  • Increased muscle mass and strength
  • Improved mood
  • Improved cognitive function
  • Decreased frailty
  • Reduced osteoporosis risk

It is important for physicians to know and inform patients that there is a time-dependent and symptom-specific onset of testosterone treatment effects.3 This means that it takes varying amount of time for specific effects of testosterone treatment to manifest. While improvements in libido and vigor occur within the first 3 months, improvements in erectile function, insulin sensitivity, glycemic control, lipids, body composition (fat loss and muscle mass gain) and bone density can take up to 12 months to appear. Body composition parameters keep improving for 10+ years.4

Age itself need not be a contraindication to testosterone treatment of elderly men with hypogonadism.5 The benefits of restoring testosterone levels in men with hypogonadism are not significantly different between men older than 65 years of age and younger men.5 There are no indications of worse side effects in elderly men. The effects on prostate and urinary function and hematocrit are within safe margins.5

It is not unusual to have obese type 2 diabetes patients who have poor glycemic control, little if any weight loss, and failure of the treatment plan. In these patients, evaluating testosterone levels often reveals hypogonadism and testosterone treatment can reverse the situation, improve laboratory values and eventually even achieve complete remission of their diabetes.6

Osteoporosis remains under-recognized and undertreated in men, more so than in women.7 This adds considerable fracture burden and health care costs and reduces quality of life in affected men. In a population of hypogonadal patients who were diagnosed with osteoporosis at baseline, treatment with testosterone undecanoate for 6 years increased T-scores by +1.5 points.8 This reclassified patients from osteoporosis to osteopenia, and reduced the calculated fracture risk by 50%.

Sarcopenia is common in hypogonadal men, who often have reduced lean body mass and muscle strength, and poor physical performance.9 Besides weakness, men with sarcopenia often gain more body fat, which makes it even harder for them to move and be physically active. A notable study found that compared with placebo, testosterone treatment in healthy men ≥60 years old for 3 years resulted in significantly greater improvements in stair-climbing power, muscle mass, chest-press strength and leg-press power.10

Frailty is a clinical syndrome characterised by reduced physiologic reserve affecting multiple organ systems and is associated with increased risk of falls, fractures, morbidity, hospitalisation and death.11 As clinicians we owe it to our patients to explore the role of testosterone in halting the progression of frailty. Over time, this may improve quality of life and maintain functional independence.


 

Speakers

Dr. David Edwards

Dr David Edwards
Chipping Norton, Oxfordshire, UK
Past President of the British Society for Sexual Medicine (BSSM)
Chairman of the Primary Care Testosterone Advisory Group (PCTAG)

References

  • Hackett G. An update on the role of testosterone replacement therapy in the management of hypogonadism. Ther Adv Urol. 2016 Apr;8(2):147-60. Return to content
  • Hackett G, Krychman M, Baldwin D, Bennett N, El-Zawahry A, Graziottin A, Lukasiewicz M, McVary K, Sato Y, Incrocci L. Coronary Heart Disease, Diabetes, and Sexuality in Men. J Sex Med. 2016 Jun;13(6):887-904. Return to content
  • Saad F, Aversa A, Isidori AM, Zafalon L, Zitzmann M, Gooren L. Onset of effects of testosterone treatment and time span until maximum effects are achieved. Eur J Endocrinol. 2011 Nov;165(5):675-85. Return to content
  • Saad F, Yassin A, Doros G, Haider A. Effects of long-term treatment with testosterone on weight and waist size in 411 hypogonadal men with obesity classes I-III: observational data from two registry studies. Int J Obes. 2016;40(1):162-70. Return to content
  • Saad F, Yassin A, Haider A, Doros G, Gooren L. Elderly men over 65 years of age with late-onset hypogonadism benefit as much from testosterone treatment as do younger men. Korean J Urol. 2015 Apr;56(4):310-7. Return to content
  • Haider A, Haider KS, Saad F. Remission of type 2 diabetes in a hypogonadal man under long-term testosterone therapy. Endocrinol Diabetes Metab Case Rep. 2017 Sep 4;2017:17-0084. Return to content
  • Laurent M, Gielen E, Claessens F, Boonen S, Vanderschueren D. Osteoporosis in older men: recent advances in pathophysiology and treatment. Best Pract Res Clin Endocrinol Metab. 2013 Aug;27(4):527-39. Return to content
  • Haider A, Meergans U, Traish A, Saad F, Doros G, Lips P, Gooren L. Progressive Improvement of T-Scores in Men with Osteoporosis and Subnormal Serum Testosterone Levels upon Treatment with Testosterone over Six Years. Int J Endocrinol. 2014;2014:496948. Return to content
  • Krasnoff JB, Basaria S, Pencina MJ, Jasuja GK, Vasan RS, Ulloor J, Zhang A, Coviello A, Kelly-Hayes M, D'Agostino RB, Wolf PA, Bhasin S, Murabito JM. Free testosterone levels are associated with mobility limitation and physical performance in community-dwelling men: the Framingham Offspring Study. J Clin Endocrinol Metab. 2010 Jun;95(6):2790-9. Return to content
  • Storer TW, Basaria S, Traustadottir T, Harman SM, Pencina K, Li Z, Travison TG, Miciek R, Tsitouras P, Hally K, Huang G, Bhasin S. Effects of Testosterone Supplementation for 3 Years on Muscle Performance and Physical Function in Older Men. J Clin Endocrinol Metab. 2017 Feb 1;102(2):583-593 Return to content
  • Saad F, Röhrig G, von Haehling S, Traish A. Testosterone Deficiency and Testosterone Treatment in Older Men. Gerontology. 2017;63(2):144-156 Return to content