Against Testosterone Treatments for Older People
This cutting opinion piece is written in opposition to the prevalence of testosterone therapy, offered in many cases with the (dubious) promise of it being a way to push back the advance of aging. Hormone therapies in general are not to be taken lightly, but are widely used. Anyone should be free to try whatever they feel may work for them, but this approach may not be justified for most people given the balance of risk and benefit. That isn't a justification for restriction of personal freedom, but rather for greater efforts to educate in the face of overly enthusiastic marketing.
It is not easy in the present environment for endocrinologists to avoid being drawn, however reluctantly, into testosterone misuse. Many endocrinologists are referred patients with a single, marginally low blood testosterone measurement seeking testosterone treatment for "hypogonadism". Under the misguidance of numerous extant guidelines or other manifestos, encourage excessive testosterone prescribing where there is any clinical doubt, which is almost always. They may fear that if they do not succumb to prescribing on demand, the patient will go doctor shopping and get the testosterone they think they need or demand elsewhere. These dilemmas are enlivened, if not enlightened, by concerted marketing and papers emanating from pharma, upscale single-issue men's health clinics, and academic enthusiasts. These rarely highlight the vested commercial interests, where present, promoting testosterone use outside approved indications under the disease-mongering rubric of "hypogonadism".
Testosterone is unique among hormones for its high level of public recognition, which unfortunately is imbued with fantasies and fictions unrelated to endocrine reality, an enchantment that easily unlocks latent but irrational wishes for rejuvenation. Reproductive medicine is unique in that, unlike other medical specialties, virtually everyone's personal experience of sex and reproduction provides them with the subjective confidence they possess sound insight into reproductive biology and medicine without needing recourse to the established objective facts. This particularly extends to beliefs about what testosterone is and does biologically. This illusion of sophisticated expertise forms a powerful coupling with tenacious wishful thinking. This latent demand is readily entrained by clever marketing from pharma and other commercial enterprises that promotes testosterone's use as an anti-ageing or sexual dysfunction tonic.
Testosterone prescribing for men without pathological hypogonadism is a therapeutic illusion in search of a definition. It is fostered by wishful thinking of an affluent populace with eyes mistily focused on the mirage of rejuvenation. The public health consequences of the recent epidemic-like increase in testosterone prescribing on cardiovascular and prostate health and iatrogenic androgen dependence remain to be evaluated over coming decades. At best it may have little adverse impact but there could be detrimental changes in cardiovascular and/or prostate health. Some evidence suggests that significant numbers of men who start testosterone treatment may have difficulty stopping it even if it proves ineffective as they become androgen dependent from androgen deficiency withdrawal symptoms while their endogenous testosterone production resumes, albeit slowly.