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How well informed are general practitioners and cardiologists about testosterone deficiency and its consequences?

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A rapidly growing body of medical research is showing that testosterone deficiency (aka hypogonadism and low-T) is strongly associated with a wide range of detrimental health outcomes [1, 2], and that testosterone replacement therapy improves those health parameters that are negatively affected by testosterone deficiency.[2, 3]
 
Therefore, leading testosterone scientists now view testosterone deficiency as a cardiovascular risk factor that contributes to the development of cardiovascular disease.[4-7]
 
As general practitioners and cardiologists primarily care for these patients with cardiovascular disease, a survey study was conducted to assess their knowledge, beliefs and clinical practice with respect to testosterone deficiency and cardiovascular health.[8]
 
METHODS: [8]
 
A questionnaire was distributed to 20 cardiologists and 128 family practitioners in Victoria, British Columbia. Of the 13 questions, 10 assessed knowledge and beliefs on testosterone deficiency and 3 assessed current practice patterns. 
 
RESULTS: 
 
Most respondents believed that testosterone deficiency is a medical condition (66.7%) and could negatively affect body composition (62%), but a similar majority was unsure whether it was a cardiac risk factor (66.7%). 
 
While most believed that testosterone replacement therapy could improve exercise tolerance (62%), most were unsure if it was beneficial in cardiac patients. 
 
Cardiologists were significantly less likely to believe that testosterone deficiency was beneficial in preventing recurrent heart attack (myocardial infarction) and improving oxygen supply to the heart (myocardial perfusion). 
 
Over half of the respondents (58.8%) said they were unsure whether testosterone deficiency could contribute to low HDL (high-density lipoprotein, aka the “good” cholesterol) levels.
 
The vast majority (88%) of general practitioners and cardiologists did not screen their cardiac patients for testosterone deficiency. If a patient was identified as having hypogonadism, only 23.5% would treat the patient themselves, and 27.5% would refer to an endocrinologist.
 
CONCLUSION: 
 
Despite its high prevalence in cardiac patients, testosterone deficiency is not well-understood by general practitioners and cardiologists; they lack knowledge on its deleterious cardiovascular effects.[8]
 

Comments 

 
While testosterone deficiency is an acknowledged cardiovascular risk factor among prominent hypogonadism researchers, this survey clearly shows that the large majority of primary care physicians and cardiologists are lagging far behind in knowledge (or willingness to abandon old school dogma) about the health consequences of testosterone deficiency.
 
 
Studies show that testosterone replacement therapy improves exercise tolerance in both healthy men [9] and in cardiac patients.[10-12] In fact, cardiac patients are the ones to benefit the most. Several studies shows that in men with known angina by treadmill testing, testosterone replacement therapy significantly increases time to ischemia.[10-12] These results are consistent with other studies in humans in which testosterone administration has been shown to induce vasodilation of the coronary [13] and brachial arteries.[14, 15] Testosterone replacement therapy also benefits men with congestive heart failure by significantly improving performance in the 6 minute walk test, incremental shuttle walk test, and/or peak oxygen consumption, and overall exercise capacity, compared to placebo.[16-20] No significant adverse cardiovascular events were noted.[16-18] Two additional, more recent placebo-controlled trials have confirmed beneficial functional effects of testosterone therapy in men with congestive heart failure.[21, 22]
 
It is also documented that testosterone deficiency is associated with reduced HDL levels [23], and that physiological restoration of testosterone levels with testosterone replacement therapy increases HDL levels.[24-30]
 
The finding that most primary care physicians and cardiologists do not screen their patients for testosterone deficiency is a red flag, as the prevalence of obesity, metabolic syndrome and diabetes is epidemic in today’s society, and it is well documented that testosterone deficiency in men with those conditions is extraordinary common, regardless of age. Specifically, in those men, the prevalence of testosterone deficiency ranges from 35% to almost 80%.[31-35]
 
The results from this survey underscore the importance for men to be pro-active about their own health and specifically request testing for testosterone deficiency if they are having symptoms/signs of hypogonadism. 
 
In a sense, every man, even the young and healthy, should have his testosterone levels checked (plus SHBG, estradiol, PSA, at a minimum) just to establish his healthy baseline. This is important because relative changes in testosterone levels over time may be a better predictor of impending testosterone deficiency and health deterioration than are the actual levels of total testosterone and/or free or bioavailable testosterone.[36] 
 
Also, because the testosterone reference range is quite wide, every man needs to find his own optimal testosterone level. The reference range for total testosterone (measured by LC-MS/MS, the gold standard testosterone assay) spans all the way from approximately 350 to 1200 ng/dL [37]. This wide range leaves a lot of room for expression of individual variation, i.e. significant decreases in testosterone levels that are still within the reference range. For example, a 50% decrease in testosterone levels will likely negatively impact most men. However, if a man’s healthy optimal baseline is in the upper end of the reference range, let’s say 1000 ng/dL, him reaching 500 mg/dL will not qualify for hypogonadism diagnosis if the current diagnostic criteria are used, which define biochemical hypogonadism as a total testosterone level below 300 ng/dL (US Endocrine Society) [38] or below 340 ng/dL (European Clinical Guidelines).[39]
 
Finding your optimal healthy baseline testosterone level can only be done via regular blood testing, staring early in life. This will provide an invaluable personal benchmark against which to track hormonal changes over time. If your doctor denies you even hormone testing, get another doctor!
 
 
 
For more info on the negative effects of testosterone deficiency and the benefits of testosterone therapy, check out:
 
 
 
 

References:

1.            Traish, A.M., Adverse health effects of testosterone deficiency (TD) in men. Steroids, 2014. 88C: p. 106-116.

2.            Mesbah Oskui, P., et al., Testosterone and the cardiovascular system: a comprehensive review of the clinical literature. J Am Heart Assoc, 2013. 2(6): p. e000272.

3.            Traish, A.M., Outcomes of testosterone therapy in men with testosterone deficiency (TD): Part II. Steroids, 2014.

4.            Corona, G., et al., Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study. European Journal of Endocrinology / European Federation of Endocrine Societies, 2011. 165(5): p. 687-701.

5.            Jones, T.H., Testosterone deficiency: a risk factor for cardiovascular disease? Trends Endocrinol Metab, 2010. 21(8): p. 496-503.

6.            Maggio, M. and S. Basaria, Welcoming low testosterone as a cardiovascular risk factor. Int J Impot Res, 2009. 21(4): p. 261-4.

7.            Ullah, M.I., et al., Testosterone deficiency as a risk factor for cardiovascular disease. Horm Metab Res, 2011. 43(3): p. 153-64.

8.            Wallis, C.J., H. Brotherhood, and P.J. Pommerville, Testosterone deficiency syndrome and cardiovascular health: An assessment of beliefs, knowledge and practice patterns of general practitioners and cardiologists in Victoria, BC. Can Urol Assoc J, 2014. 8(1-2): p. 30-3.

9.            Srinivas-Shankar, U., et al., Effects of testosterone on muscle strength, physical function, body composition, and quality of life in intermediate-frail and frail elderly men: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab, 2010. 95(2): p. 639-50.

10.          English, K.M., et al., Low-dose transdermal testosterone therapy improves angina threshold in men with chronic stable angina: A randomized, double-blind, placebo-controlled study. Circulation, 2000. 102(16): p. 1906-11.

11.          Webb, C.M., et al., Effect of acute testosterone on myocardial ischemia in men with coronary artery disease. Am J Cardiol, 1999. 83(3): p. 437-9, A9.

12.          Rosano, G.M., et al., Acute anti-ischemic effect of testosterone in men with coronary artery disease. Circulation, 1999. 99(13): p. 1666-70.

13.          Webb, C.M., et al., Effects of testosterone on coronary vasomotor regulation in men with coronary heart disease. Circulation, 1999. 100(16): p. 1690-6.

14.          Ong, P.J., et al., Testosterone enhances flow-mediated brachial artery reactivity in men with coronary artery disease. Am J Cardiol, 2000. 85(2): p. 269-72.

15.          Kang, S.M., et al., Effect of oral administration of testosterone on brachial arterial vasoreactivity in men with coronary artery disease. Am J Cardiol, 2002. 89(7): p. 862-4.

16.          Caminiti, G., et al., Effect of long-acting testosterone treatment on functional exercise capacity, skeletal muscle performance, insulin resistance, and baroreflex sensitivity in elderly patients with chronic heart failure a double-blind, placebo-controlled, randomized study. J Am Coll Cardiol, 2009. 54(10): p. 919-27.

17.          Malkin, C.J., et al., Testosterone therapy in men with moderate severity heart failure: a double-blind randomized placebo controlled trial. Eur Heart J, 2006. 27(1): p. 57-64.

18.          Pugh, P.J., et al., Testosterone treatment for men with chronic heart failure. Heart, 2004. 90(4): p. 446-7.

19.          Iellamo, F., et al., Testosterone therapy in women with chronic heart failure: a pilot double-blind, randomized, placebo-controlled study. J Am Coll Cardiol, 2010. 56(16): p. 1310-6.

20.          Toma, M., et al., Testosterone supplementation in heart failure: a meta-analysis. Circ Heart Fail, 2012. 5(3): p. 315-21.

21.          Mirdamadi, A., et al., Beneficial effects of testosterone therapy on functional capacity, cardiovascular parameters, and quality of life in patients with congestive heart failure. Biomed Res Int, 2014. 2014: p. 392432.

22.          Stout, M., et al., Testosterone therapy during exercise rehabilitation in male patients with chronic heart failure who have low testosterone status: a double-blind randomized controlled feasibility study. Am Heart J, 2012. 164(6): p. 893-901.

23.          Simon, D., et al., Association between plasma total testosterone and cardiovascular risk factors in healthy adult men: The Telecom Study. J Clin Endocrinol Metab, 1997. 82(2): p. 682-5.

24.          Traish, A.M., et al., Long-term testosterone therapy in hypogonadal men ameliorates elements of the metabolic syndrome: an observational, long-term registry study. Int J Clin Pract, 2014. 68(3): p. 314-29.

25.          Heufelder, A.E., et al., Fifty-two-week treatment with diet and exercise plus transdermal testosterone reverses the metabolic syndrome and improves glycemic control in men with newly diagnosed type 2 diabetes and subnormal plasma testosterone. J Androl, 2009. 30(6): p. 726-33.

26.          Zitzmann, M. and E. Nieschlag, Androgen receptor gene CAG repeat length and body mass index modulate the safety of long-term intramuscular testosterone undecanoate therapy in hypogonadal men. J Clin Endocrinol Metab, 2007. 92(10): p. 3844-53.

27.          Haider, A., et al., Hypogonadal obese men with and without diabetes mellitus type 2 lose weight and show improvement in cardiovascular risk factors when treated with testosterone: an observational study. . Obes Res Clin Pract 2013.

28.          Haider, A., et al., Effects of Long-Term Testosterone Therapy on Patients with “Diabesity”: Results of Observational Studies of Pooled Analyses in Obese Hypogonadal Men with Type 2 Diabetes. International Journal of Endocrinology, 2014: p. Article ID 683515.

29.          Mitkov, M.D., I.Y. Aleksandrova, and M.M. Orbetzova, Effect of transdermal testosterone or alpha-lipoic acid on erectile dysfunction and quality of life in patients with type 2 diabetes mellitus. Folia Med (Plovdiv), 2013. 55(1): p. 55-63.

30.          Yassin, D.J., et al., Long-term testosterone treatment in elderly men with hypogonadism and erectile dysfunction reduces obesity parameters and improves metabolic syndrome and health-related quality of life. J Sex Med, 2014. 11(6): p. 1567-76.

31.          Caldas, A.D., et al., Relationship between insulin and hypogonadism in men with metabolic syndrome. Arq Bras Endocrinol Metabol, 2009. 53(8): p. 1005-11.

32.          Laaksonen, D.E., et al., The metabolic syndrome and smoking in relation to hypogonadism in middle-aged men: a prospective cohort study. J Clin Endocrinol Metab, 2005. 90(2): p. 712-9.

33.          Singh, S.K., R. Goyal, and D.D. Pratyush, Is hypoandrogenemia a component of metabolic syndrome in males? Exp Clin Endocrinol Diabetes, 2011. 119(1): p. 30-5.

34.          Pellitero, S., et al., Hypogonadotropic hypogonadism in morbidly obese males is reversed after bariatric surgery. Obes Surg, 2012. 22(12): p. 1835-42.

35.          Biswas, M., et al., Total and free testosterone concentrations are strongly influenced by age and central obesity in men with type 1 and type 2 diabetes but correlate weakly with symptoms of androgen deficiency and diabetes-related quality of life. Clin Endocrinol (Oxf), 2012. 76(5): p. 665-73.

36.          Holm, A.C., et al., Change in testosterone concentrations over time is a better predictor than the actual concentrations for symptoms of late onset hypogonadism. Aging Male, 2011. 14(4): p. 249-56.

37.          Bhasin, S., et al., Reference ranges for testosterone in men generated using liquid chromatography tandem mass spectrometry in a community-based sample of healthy nonobese young men in the Framingham Heart Study and applied to three geographically distinct cohorts. J Clin Endocrinol Metab, 2011. 96(8): p. 2430-9.

38.          Bhasin, S., et al., Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab, 2010. 95(6): p. 2536-59.

39.          Wang, C., et al., Investigation, treatment, and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA, and ASA recommendations. J Androl, 2009. 30(1): p. 1-9.

 
 
Last modified on Sunday, 16 November 2014 23:34
Monica

Medical Writer & Nutritionist

MSc Nutrition

University of Stockholm & Karolinska Institute, Sweden 

   Baylor University, TX, USA

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