There are several conditions associated with a high prevalence of low testosterone levels, such as chronic obstructive pulmonary disease, osteoporosis, and infertility. Men may be screened if specific symptoms or signs are reported, such as reduced libido, loss of body hair, breast discomfort, or hot flashes. However, there has been more published research about the link between low testosterone levels (i.e. hypogonadism) and type 2 diabetes mellitus. In this blog, I wanted to focus on testosterone replacement therapy as June is Men’s Health Month.
Testosterone replacement therapy is commonly used to restore testosterone level back to physiologic levels, in which can improve symptoms. Testosterone replacement therapy should be given to those with a diagnosis of hypogonadism, which is the presence of symptoms with low testosterone levels. Testosterone levels should be obtained between 7 and 11 am and also be confirmed with a second diagnostic test – similar to fasting glucose levels for diabetes diagnosis. There are several formulations for testosterone replacement therapy, such as intramuscular, transdermal (i.e. gel, patch, solution), buccal tablet, or subcutaneous pellets. Each project as its advantages and disadvantages and will be dosed differently. The appropriate product should be selected for the patient. Often, in clinical practice, the most commonly prescribed products are transdermal formulations. These specific projects are dosed once-daily and have flexible application instructions. However, a concern is risk of transfer to another individual based on the site of transdermal application. Among the transdermal products, the gel and solution would be the most convenient, as the patch can cause more skin irritation. Once a patient is prescribed testosterone replacement therapy, monitoring should be completed on a 3-6 months basis. Symptoms, adverse events, testosterone, and complete blood count should be monitored. Lipid panel should also be monitored based on the 2013 cholesterol guidelines. Bone mineral density tests can be completed as 1 to 2 years of therapy, especially among those with a diagnosis of osteopenia, osteoporosis, or fracture.
In addition to more evidence about testosterone and diabetes, there has been published data about testosterone replacement therapy and increased risk of cardiovascular event. In a retrospective cohort study, charts of patients with low testosterone levels who underwent coronary angiography were reviewed. Based on the information, there seemed to be a higher frequency of death and cardiovascular events among those receiving testosterone replacement therapy. In another retrospective trial, individuals younger or older than 65 years had a high risk of a myocardial infarction, based on relative risk of 2.07 and 1.90, respectively. It is important to consider these risks and warnings, especially among patients with type 2 diabetes, whether or not the patient has a documented history of heart disease.