In recent months, a couple of articles have been published linking testosterone therapy to an increased risk of heart attacks and strokes. This has spurred an onslaught of ads by attorneys on TV advising that anyone that has used testosterone and had a heart attack may be entitled to substantial financial compensation. It is troubling that this type of solicitation can happen even before all of the scientific facts are in to justify it. Sadly, it reminds me of the silicon breast implant litigation that netted a $3.7 billion settlement despite an “astonishing lack of scientific evidence” that silicon implants caused any illness or disease. In fact, silicon implants are back on the market now. A look at the full body of studies done regarding testosterone and heart disease paints a very different picture than the two recent studies suggest.
A NY Times article highlighting a study showing an association between testosterone and risk of MI (myocardial infarction or heart attack) garnered a great deal of media attention. It is a retrospective observational study, from which causation cannot be determined. In brief, here are the findings: In men under 65 without a history of heart disease, there was no increased risk, in fact about a 10% reduction in risk though not statistically significant. In men over 65 there was a significant increase in risk whether they had previous heart disease or not. They also looked at whether giving the men prescriptions for Viagra was associated with an increase in heart attacks, presumably to see if increased sexual activity alone was the cause of the heart attacks. They found that the Viagra prescriptions did not correlate with heart attacks. But there is no report of whether the men actually had increased sexual activity. What we do not know about the testosterone that was prescribed: type of testosterone? topical vs injectable? Dose? Levels achieved? Amount of aromatization or conversion to active metabolites? Without having the starting levels documented, we do not even know if the results apply to men with low testosterone or men with normal levels taking testosterone. I do not think this study provides enough information to add much to the conversation about testosterone therapy.
The Journal of the American Medical Association (JAMA) published a study Nov 2013 that looked at VA Hospital patients with low testosterone levels. The men were about 62 years old, and were given testosterone replacement therapy for about a year. But what the authors found was surprising: the men who got testosterone did worse than the men who didn’t! Specifically, they had a small increase in heart attacks and strokes. It’s especially surprising since a very similar trial was published just last year in the Journal of Clinical Endocrinology and Metabolism and got exactly the opposite result! In that 2012 study, the men were 61 years old, were given testosterone via injection, gel or patch and followed for 43 months. The mortality in testosterone-treated men was 10.3% compared with 20.7% in untreated men (P <0.0001). Conclusions: In an observational cohort of men with low testosterone levels, testosterone treatment was associated with decreased mortality compared with no testosterone treatment. What was the difference? The two groups of men studied were very different. In the 2013 study, the men were in terrible health to start: 20% had had a prior heat attack, 18% had Congestive Heart Failure, 55% had confirmed obstructive coronary artery disease by angiogram. In the 2012 study showing reduced risk, only 20% had heart disease of any type.
Since the publication of the November study in JAMA, the authors have had to make several corrections to their data. An international ad hoc coalition of physicians, the Androgen Study Group, led by renowned Harvard professor and testosterone researcher, Dr. Abraham Morgentaler have called for a retraction of the article, citing the faulty data, and calling its credibility into question.
A comprehensive review article (J Am Heart Assoc. 2013;2:e000272) published in JAMA Dec 2013 concluded: “ This review article has demonstrated that normal testosterone levels play an important role in maintaining cardiovascular health, and testosterone replacement therapy in men with hypogonadism (low testosterone) improves obesity, type 2 diabetes, myocardial ischemia, exercise capacity, and QTc length (an EKG parameter associated with arrhythmias).”
Another review article (J Clin Endocrinol Metab, June 2012, 97(6):2050–2058) concluded: “…it has now been demonstrated in several large longitudinal cohort studies of men with and without coronary disease that low baseline testosterone is a significant risk marker of increased all-cause and cardiovascular mortality. More importantly, once hypogonadism is diagnosed, replacement therapy has a beneficial anti-ischemic effect, along with beneficial effects on lipids, glucose metabolism, inflammatory cytokine profiles, lean body mass, blood clotting profiles and patient well-being.”
What does this all mean? More research is needed and the last word on testosterone therapy ( a large scale prospective trial) has yet to be written. But what do we know now?
- The majority of evidence shows a beneficial and protective effect of testosterone on the heart, brain and prostate
- Low testosterone has been associated with an increased risk of heart disease, type 2 diabetes, obesity, prostate cancer, and death from all causes
- Testosterone therapy improves lean muscle mass and strength, reduces belly fat, heightens mood, improves erectile quality, and restores youthful libido, vitality and vigor
Like any other legitimate medical therapy, it may not be for everyone. But for thousands of men, appropriately evaluated for low testosterone and treated in the context of an overall health improvement and lifestyle modification program, it is an essential and extremely beneficial therapy. If you or someone you know has concerns about “low T”, you can complete our “low T quiz” or call 860-561-2294 to schedule a confidential consultation.