Testosterone Replacement Therapy
A man’s testosterone level starts to decline as they reach their late twenties. As this decline occurs, men can start to go through physical as well as emotional changes. Today, with the high level of toxin exposure, especially to xenoestrogens (natural and artificial estrogen mimickers), which are endocrine disruptors, e.g., soy products, plastics, herbicides, pesticides, and personal care products, testosterone levels are at an epidemic low. Unfortunately, even many young men in their 20s and 30s must deal with low testosterone (low T) side effects.
Common side effects of low T:
Decreased libido
Erectile dysfunction
Low energy
Lack of motivation
Decreased muscle mass
Decreased strength
Increased adiposity (fat accumulation)
Depression/anxiety
Increased risk of heart disease
Increased risk of diabetes
Testosterone replacement therapy (TRT) is a standard treatment for men with hypogonadism (low T) because it is highly efficacious in ameliorating and sometimes resolving low T side effects. Unfortunately, many providers mistakenly believe there is an association between testosterone, benign prostate hyperplasia (BPH), and worsening lower urinary tract symptoms LUTS. Moreover, if an allopathic provider does prescribe testosterone, the dose is too low in many cases, and they are not looking at the patient’s overall health and well-being.
Symptoms of BPH:
Frequent urination
Urgency
Nocturia (waking at night to urinate)
Weak urine stream
Stream intermittency
The FDA requires warning about the risk of testosterone therapy, worsening BPH, potential risk of prostate cancer, and increased prostatic specific antigen (PSA). Contrary to this warning, testosterone therapy seems beneficial in preventing BPH/LUTS (Saad, 2007; Yassin et al., 2014). Moreover, most research has concluded that there is little to no evidence that men treated with testosterone have higher risks for BPH and associated symptoms (Reynaud et al., 2015). In a randomized control trial of 44 late-onset hypogonadal men, Marks et al. (2006) found that those treated with TRT did not significantly increase prostate tissue testosterone or DHT levels, or gene alteration, despite having significantly increased levels of serum testosterone.
Some authors claim the long-held belief that prostatic growth is related to serum testosterone levels originates from a paper published in 1941 by Charles Huggins and Clarence Hodges. Their study demonstrated that castration resulted in prostate cancer regression and testosterone administration caused prostate growth. This turning point study included one subject, a patient that had prostate cancer at the onset of the study (Huggins & Hodges, 2002).
Subsequent research has shown that prostate volume increases with time independent of testosterone levels. Hence, a man’s prostate will continue to grow despite declining T levels with age. Furthermore, younger men do not see magnified prostatic growth despite their higher T levels (Fig 1). It is also worth noting that increasing prostate size does not correlate with worsening LUTS or BPH (NIH, 2015; Heritage Pharmaceuticals, 2021; Kang et al., 2015).
Fig, 1 Bass & Kohler (2016)
According to Kathrins et al. (2015), a systematic review of the literature between 1994 and 2015 that included 35 trials does not support a causal relationship between TRT, new or worsening LUTS, and prostate volume. Moreover, the researchers did not find high-quality evidence that supports guidelines recommendations that TRT is contraindicated in men with severe-range LUTS.
Finally, a large proportion of hypogonadal men will become overweight, obese, and insulin-resistant leading to an increased risk of type 2 diabetes and cardiovascular disease (wang et al., 2011; Saad et al., 2012; Corona et al., 2011; Traish et al., 2009). TRT can help to ameliorate these potentially deadly risk factors. Several studies of hypogonadal men treated with T demonstrated increased muscle mass, reduced fat mass significantly, reduced serum low-density lipoprotein (LDL) levels, and improved blood pressure and heart rate (Yassin & Doros, 2013).
Informed consent is both an ethical and legal obligation of medical practitioners in the US and is derived from a patient’s right to decide what happens to their body. Informed consent involves a healthcare provider educating a patient about the risks, benefits, and alternatives to the intervention, e.g., medication, surgery, and COVID jabs. Informed consent is in the American Medical Association’s Code of Ethics, which states, “successful communication in the patient-physician relationship fosters trust and supports shared decision making.” How often did physicians and other medical professionals breach the AMA’s Code of Ethics daily over the last two years?
While the FDA warning for TRT remains without high-level evidence to support their position, patients should continue to be warned about the potential worsening of LUTS if considering treatment. However, patients also should be informed about the evidence that concludes testosterone does not contribute to BPH and may play an important part in the role of improving BPH/LUTS, their risk of heart disease, libido, erectile disfunction, fatigue, decreased strength, decreased muscle mass, and depression as males age.
If one thinks they have a testosterone deficiency, it is essential to discuss their physical and mental symptoms with a treatment provider, including any potential risks and benefits of treatment. For more on the risks associated with low T read Did You Know… Low testosterone is not without consequences.
Supplements that support the prostate:
Ultra Prostate Formula – Just two capsules daily include a dozen ingredients that support prostate cell health, healthy urination, help inhibit excess estrogen, promote a healthy inflammatory response, and more.
Baas, W., & Köhler, T.S. (2016). Testosterone Replacement Therapy and BPH/LUTS. What is the Evidence? Current Urology Reports, 17, 46. https://doi.org/10.1007/s11934-016-0600-8
Corona, G., et al. (2011). Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study. European Journal of Endocrinology, 165, 687–701.
Haring, R., et al. (2010). Low serum testosterone levels are associated with increased risk of mortality in a population-based cohort of men aged 20–79. European Heart Journal, 31(12), 1494–1501, https://doi.org/10.1093/eurheartj/ehq009
Heritage Pharmaceuticals. (2021). Terazosin. Retrieved from file:///C:/Users/mindb/Dropbox/Tenpenny%20ideas%20and%20info/Testosterone%20Hormones%20papers%20and%20books/HRT%20and%20prostate/20211111_1dabd4d6-3023-460a-8577-08b3690e7c93.pdf
Huggins, C., & Hodges, C. V. (2002). Studies on prostatic cancer: I. The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. The Journal of urology, 168, 9-12. https://doi.org/10.1016/S0022-5347(05)64820-3
Kang, M., et al. (2015). Urodynamic Features and Significant Predictors of Bladder Outlet Obstruction in Patients with Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia and Small Prostate Volume. The Journal of Urology, https://doi.org/10.1016/j.urology.2015.11.027
Kathrins, M., et al. (2015). The Relationship Between Testosterone-Replacement Therapy and Lower Urinary Tract Symptoms: A Systematic Review. Urology, DOI:https://doi.org/10.1016/j.urology.2015.11.006
Marks, L. S., et al. (2006). Effect of testosterone replacement therapy on prostate tissue in men with late onset hypogonadism: a randomized controlled trial. JAMA, 296, 2351–61.
DOI: 10.1001/jama.296.19.2351
National Institute of Health [NIH]. (2022). BPH and Male LUTS: Intersection between Pathology and Disease [Virtual meeting]. Received from https://www.niddk.nih.gov/news/meetings-workshops/2022/male-luts-prostate-workshop
Raynaud, J. P. et al. (2013). Prostate specific antigen (PSA) concentrations in hypogonadal men during 6 years of transdermal testosterone treatment. British Journal of Urology Int, 111(6), 880–890. DOI: 10.1111/j.1464-410X.2012.11514.x
Saad, F., et al. (2007). An exploratory study of the effects of 12-month administration of the novel long-acting testosterone undecanoate on measures of sexual function and the metabolic syndrome. Archives Andrology, 53(6), 353-7. doi: 10.1080/01485010701730880.
Saad, F., et al. (2012). Testosterone as potential effective therapy in treatment of obesity in men with testosterone deficiency: a review. Current Diabetes Reviews. 8(2), 131–143. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296126/
Traish, A. M., et al. (2009). The dark side of testosterone deficiency: III. Cardiovascular disease. Journal of Andrology, 30, 477–494.
Wang, C., et al. (2011). Low testosterone associated with obesity and the metabolic syndrome contributes to sexual dysfunction and cardiovascular disease risk in men with type 2 diabetes. Diabetes Care, 34(7), 1669–1675. DOI: 10.2337/dc10-2339
Yassin, A. A., & Doros, G. (2013). Testosterone therapy in hypogonadal men results in sustained and clinically meaningful weight loss. Clinical Obesity 3, 73–83. doi: 10.1111/cob.12022
Yassin, D. (2014). 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. The Journal of Sexual Medicine, 11(6), 1567-1576.