During the 2010 World Series, Abbott Laboratories, maker of the testosterone supplement AndroGel, ran ads asking middle-aged men if they remembered having more energy for 18 holes of golf, more passion for the ones they love, more fun in general at some undefined time in the past. I’m not even a guy, and I was nodding. The problem, the announcer explained, could be a medical condition called low testosterone, or “low T.” Any man who longed to once again get down under the metaphorical disco ball should ask his doctor about it. You could almost hear the iPhones dialing.
Some men didn’t need the primer. In 2005, doctors wrote 2.3 million prescriptions for testosterone products. Michael, 57, an online producer in Los Angeles, started a regimen seven years ago when he realized he’d inadvertently reached middle age. His sex drive had nose-dived. He was losing muscle mass and gaining belly weight. He had the sense that he couldn’t keep up, and he felt more fearful. “In my 40s, I loved being in the world. I loved to work,” says Michael, who asked not to use his real name. “All of a sudden the physical pain of sitting at a desk and commuting becomes difficult. Running a meeting is interesting, because I’m fuzzy around the edges. It takes me days to see something coming.”
Then he started taking supplemental testosterone—first as an injection and then as AndroGel—and the maelstrom of middle age gave way. “It’s very Cocoon,” he says, laughing. “My body started to be defined. I lost this feminine weight I had been gaining. I was talking more in meetings, saying things like, Here’s what I think we should do.” The fear evaporated, his libido returned in spades, and he seriously considered buying a monster-sized truck. Forget the disco ball. Michael had found the fountain of youth.
Trouble that Starts with T
The concept of low T isn’t new. Since the 1930s, doctors have known that testosterone levels decrease about 1 percent a year, starting at some time in a man’s 30s. They’ve also known that middle-aged men have a host of sexual and nonsexual symptoms similar to Michael’s. Even the debate over whether the two observations are related—indicating a sort of male menopause, or “andropause,” that should be treated with supplemental testosterone—has raged for 70 years.
On the one hand are the conservatives who warn that testosterone isn’t a panacea for male aging. These symptoms are the natural trappings of growing older, they say, and with a dearth of long-term studies proving its safety, testosterone replacement therapy should be prescribed judiciously. “People who have the generic middle-age dwindles, they’re stressed out from work, their spouse is on their back, and they’re not exercising anymore, those folks I’m more hesitant to say should be on testosterone,” cautions Christopher Saigal, MD, associate clinical professor of urology at the David Geffen School of Medicine at the University of California, Los Angeles.
On the other hand are the believers, who say low T is a medical condition and that short-term studies, which have followed men for two or three years, show supplemental testosterone is safe. The Endocrine Society estimates that as many as 5 million men suffer from low testosterone, though as few as 1 in 20 are diagnosed and treated. To Abraham Morgentaler, MD, associate professor of urology at Harvard Medical School and author of Testosterone for Life, that’s unconscionable. “People have accused me of being a cheerleader for testosterone,” says Morgentaler, who is also the director of Men’s Health Boston. “My viewpoint is that testosterone deficiency is clearly under-recognized, undertreated, and there are a lot of men who would benefit from testosterone therapy. Done properly, it’s safe and it can make a huge difference in the life of some men.”
To T or Not to T
The testosterone debate is fueled largely by the fact that there’s a lot of wiggle room in the way doctors and patients see low T. Before deciding whether to take supplemental testosterone, it’s important to know the pros and cons, and balance benefit with risk. With that in mind, we asked the experts to answer some questions.
Who takes supplemental testosterone?
The majority of Morgentaler’s patients are men in their 50s and 60s, “who are still in reasonably good health but have just lost their mojo,” he explains. Classic symptoms are erectile dysfunction, diminished libido, changes in the nature of orgasms, low energy and vitality, fatigue, sleepiness, loss of muscle mass and more belly fat.
What is normal testosterone?
There’s no real one number for normal. The range of normal testosterone is wide, fluctuates during the day (peaking between 8 and 10 a.m.) and varies from man to man. “Some patients who have physiologically high levels can have problems with sexual function and low libido,” Saigal says, “while others with low levels are completely normal and have no sexual complaints at all.” In treatment, Morgentaler aims for the standard middle to upper range of normal, 500 to 600 ng/dl.
How is low T determined?
Here’s where it gets tricky. Blood tests are commonly used, but results can vary wildly between laboratories. What’s more, they can’t say what normal is for a particular man. “The truth is, there is not a single exact number that can separate men who have the condition from men who don’t,” says Morgentaler. “The blood test is important, but more important are the symptoms of the individual.”
What are the benefits?
The areas testosterone has clearly shown benefit are libido, increased muscle mass, decreased body fat and greater bone density, says Morgentaler. Some patients reverse erectile dysfunction, though it’s not perfect. Saigal isn’t confident the testosterone clinically improves depression, cognitive decline or low energy, though “some patients feel it really helps,” he says.
What are the risks?
The most worrisome risk is prostate cancer, but studies have proven inconsistent. In 2006 Morgentaler and colleagues published a review in European Urology that found no clinical evidence that testosterone upped prostate cancer growth, while a study in Cancer Epidemiology, Biomarkers and Prevention that same year stated just the opposite. High testosterone may also cause sleep apnea, acne, enlarged breasts, testicle shrinkage and an increased number of red blood cells, which could lead to heart attacks and strokes. “While short-term data indicates it’s safe,” Saigal says, “there’s no data for men who are on testosterone for 10 years that shows what happens to their cardiovascular profile and certain malignancies.”
Are there any alternative ways to boost T?
Herbal remedies may be helpful to combat symptoms associated with low testosterone (for instance, Korean red ginseng for erectile dysfunction and an extract from the mixture of astragalus and red sage root for chronic fatigue), but none have been shown to raise testosterone levels in men. The good news? Some evidence suggests strenuous exercise, particularly resistance training, may increase T slightly, says Morgentaler. And supplemental testosterone is bioidentical. So while it was created in a lab, the hormone in injections, gels and patches exactly mirrors the natural testosterone in your body.
How do you take it?
Testosterone can be injected, though that creates “really high peaks and really low valleys,” Saigal warns. The preferred delivery is via gel, which produces a more steady state. One caveat: the gel can spread to other people if you come in physical contact within a few hours of application.
How long are you on it?
Morgentaler tells his patients that they can stop anytime they want. “But we don’t have any way to jumpstart the system,” he explains, “so when they stop, their testosterone levels are going to go back to where they were before.
Michael learned that firsthand when he decided to go off testosterone, a weaning that left him depressed for a spell. Ultimately, he felt that the hormone had led him to make reckless choices (ahem, the monster-sized truck) and to think about sex, well, a little too much. Instead of 40-inch chrome rims, he realized that what he really wanted was something older, refined and fashionable—like an artist salon or a smoking jacket—and testosterone was keeping him thinking young and foolish. “I still keep it as an option,” says Michael, who misses the fearlessness most of all. But for now, he’s exploring the benefits of growing old gracefully. “I won’t do it until I’m 60, but I will wear an ascot.”
Testosterone Depletion Factors
While the jury is still out on natural ways to elevate your testosterone levels, we know a thing or two about what conditions—besides aging—are associated with low T.
• Poor or disordered sleep
• Long stays in the hospital
• Chronic pain medications like opioids
• Diseases like diabetes and obesity
• Vegetarian diets—one or two studies have shown that meat-eaters have higher stores of T.
• The smell of a woman’s tears—According to the journal Science, men who caught a whiff of the waterworks showed a decline in testosterone and sexual arousal.
Photos by Robert Kozek
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