© The Canadian Journal of Urology™; 21(3); June Supplement 2014
Address correspondence to Dr. Martin Miner, The Men’s
Health Center, The Miriam Hospital, 164 Summit Avenue,
Providence, RI 02906 USA
Testosterone deficiency:
myth, facts, and controversy
Martin Miner, MD,
1
Jack Barkin, MD,
2
Matt T. Rosenberg, MD
3
1
Departments of Family Medicine and Urology, Miriam Hospital, Brown University, Providence, Rhode Island, USA
2
Department of Surgery, University of Toronto, Humber River Regional Hospital, Toronto, Ontario, Canada
3
Mid Michigan Health Centers, Jackson, Michigan, USA
MINERM,BARKINJ, ROSENBERGMT. Testosterone
deficiency: myth, facts, and controversy.
Can J Urol
2014;21(Suppl 2):39-54.
Testosterone deficiency (TD) afflicts approximately 30%
of men ages 40-79 years, with an increase in prevalence
strongly associated with aging and common medical
conditions including obesity, diabetes, and hypertension.
There appears to be a strong relationship between TD
and metabolic syndrome, though the relationship is not
certain to be causal. Several studies have suggested
that repletion of testosterone in deficient men with
these comorbidities may indeed reverse or delay their
progression. While testosterone repletion has been largely
thought of in a sexual realm, we discuss its potential
role in general men’s health concerns: metabolic, body
composition, and its association with decreased all-cause
mortality.
Recent guidelines and studies have suggested variable
prevalence statistics and expanded uses of testosterone
repletion in certain populations with both biochemical
and clinical signs of testosterone deficiency. Yet, this is
not done without risk. A recent randomized placebo-
controlled trial of testosterone repletion in elderly frail
men with limited mobility has suggested potential negative
cardiovascular risks in this older, sicker group of men.
Two more recent retrospective studies of variable clinical
design and interpretation suggest testosterone poses an
increased cardiovascular risk in older men than 65 years
and younger menwith heart disease. This review examines
these and other studies, with practical recommendations
for the diagnosis of testosterone deficiency and repletion
in middle aged and older men, including an analysis of
treatment modalities and areas of concern and uncertainty.
Key Words:
testosterone deficiency, diagnosis
interest among clinicians and the public in addressing
the potential adverse metabolic and general health
issues associated with TD. However, there are limited
sources to guide decision-making in commonly seen
cases where testosterone replacement therapy (TRT)
may be considered.
Defining testosterone deficiency
Clinical practice guidelines on testosterone deficiency
in men recognize that the condition is both a
biochemical and clinical state—suspected on the basis
of symptoms but confirmed by laboratory findings.
The Endocrine Society, whose most recent clinical
practice guidelines were published in 2010,
11
defines
TD as a clinical syndrome resulting from the failure of
the testes to produce physiologic levels of testosterone
and a normal number of spermatozoa; this is caused by
disruption at one or more levels of the hypothalamic-
pituitary-gonadal (HPG) axis.
11,12
Recommendations
reflecting the views of the International Society of
Andrology (ISA), International Society for the Study
Introduction
Hypogonadism, due to all causes, henceforth
referred to as testosterone deficiency (TD), afflicts
approximately 30%of men ages 40-79, and the increase
in its prevalence is associated with aging.
1
Clinical
symptoms of TD include fatigue, decreased libido,
erectile dysfunction and negative mood states.
2-5
TD
is also associated with changes in body composition,
including decreased lean body mass, increased fat
mass, and decreased bone mineral density.
2-5
Studies
have shown a significantly increased risk of TD in
association with common medical conditions, such
as obesity, diabetes, and hypertension.
2-5
In addition,
there appears to be a strong relationship between TD
and the metabolic syndrome (Met S).
6-10
Whereas
treatment of TD in the past has been initiated primarily
for relief of sexual symptoms, there is now increasing
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