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Study Says Remedy for Low T May be...Estrogen

Turn on the TV and you’ll know that testosterone replacement therapy is on the rise. Low T is apparently a problem for a growing number of men. (If the ads are any indication, most of them are relatively young, trim, and handsome.) We are led to believe that the diagnosis and treatment of testosterone deficiency are well in hand. A new study reported September 12, 2013, in the New England Journal of Medicine suggests otherwise, that we are still early in the learning process.

Lead researcher Joel S. Finkelstein, MD, (Massachusetts General Hospital) and colleagues confirm that testosterone therapy is indeed on the upswing. Prescriptions for testosterone increased by 500% in the United States from 1993 to 2000; the rate of increase likely continues to climb. “Most testosterone prescriptions are written to treat non-specific symptoms, such as fatigue or sexual dysfunction, when… testosterone levels [fall] below the laboratory reference range,” the researchers wrote. “While convenient, this classification fails to consider the physiological consequences of specific testosterone levels,” they added. In short, testosterone therapy is hit or miss.

One factor often overlooked is the role of the female hormone estrogen. More than 80% of circulating estrogen in men is from the conversion of testosterone. “Thus, as serum testosterone levels decline, there is a concomitant decline in serum [estrogen] levels,” Finkelstein et al wrote. As we will see, ignoring the connection between testosterone and estrogen can mean the failure of therapy.

“A lot of things we think are due to testosterone deficiency are actually related to the estrogen deficiency that accompanies it,” Dr. Finkelstein told the Associated Press. Millions of men have been prescribed testosterone gel, patches or shots for complaints of diminished libido, strength and energy, but it’s not known how much they need or whether hormone replacement therapy is good, bad or neutral, Finkelstein said. (Doctors usually remedy low estrogen by giving men more testosterone and letting their bodies convert it.)

The study was designed to allow Finkelstein and his team to assess the effects of different levels of each hormone (testosterone and estrogen) on strength, body composition, and sexual function. It involved 400 healthy men, ages 20 to 50, who were first given monthly shots of a drug to temporarily reduce their testosterone production to childhood levels. They were then given various doses of testosterone gel or a placebo gel. Half were also given another drug to prevent testosterone’s conversion to estrogen.

The study was designed to answer many questions about the physiological consequences of specific levels of testosterone and estrogen. As you can imagine, the results are detailed and complex. The bottom line findings are, however, quite clear and transparent.

After examining the effect of various doses of testosterone and resulting hormonal levels over 16 weeks, with and without estrogen suppression, the researchers found that muscle size and strength depended on testosterone, body-fat mass depended on estrogen, and that both hormones were needed to maintain normal sex drive and performance.

The specific findings are enlightening and perhaps reassuring. While the dose of testosterone required to prevent adverse changes varies considerably, they found that generally speaking fat accumulation began with a testosterone level of approximately 300 to 350 ng per deciliter, while lean mass and strength were preserved until testosterone dropped to 200 or below. The researchers suggested that testosterone supplementation “seems justified” in men with testosterone levels at 200 or below. “However, some men have alterations in these functional outcomes at lower or higher testosterone levels,” Finkelstein et al observed.

Estrogen levels must also be taken into considerations. When estrogen is low, more testosterone may be needed. Dr. John Morley, an expert on hormone therapies and aging at St. Louis University, who was not involved in the study, told the AP that doctors tend to try a lower dose of testosterone and abandon it if it doesn’t work  Some men may need more, he said.

Doctors and their patients must work together on the need for hormone replacement therapy; whether it’s necessary and, if so, the amount required. The need for lifestyle changes should be assessed and possible side effects must be considered.

We don’t know the long term effects of testosterone replacement. All drugs have side effects.

Further research is needed, but these findings may boost the case for giving testosterone to reduce or prevent frailty in older men, according to the researchers. Twenty percent of men over 60 and 50% of men over 80 have testosterone levels at least two standard deviations below the mean level in young men.

In summary, the researchers wrote that the study “should facilitate the development of more rational approaches to the diagnosis and treatment of testosterone deficiency in men.” 

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In my latest report (2012), my doctor at the Cooper Clinic in Dallas wrote that my “hormone function is quite healthy with a serum testosterone level of 491.” I believe this is due to regular exercise (strength and endurance), a healthy eating style, and body fat control. Clearly, that is the most desirable route to healthy hormone function.

I do not use testosterone or any other form of hormone therapy.

If you believe you may have “low T,” see your doctor. Testosterone replacement may be called for, but that is not the only answer. Lifestyle change should be considered first. Testosterone alone is no more the answer then popping a vitamin pill on the way to the fast food eatery.

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