Testosterone replacement? What should I tell my patients? Evidence?

[HarryMTieboutMD]

Hi all- I couldn't find a thread on this anywhere, so I'd figure I would ask

I'm currently a psychiatry resident, and I have had several patients inquire about testosterone replacement/optimization, normal levels notwithstanding. This seems to be sort of fad-sh (but based on epidemiological evidence that avg male testosterone levels are decreasing) with a sort of "alt-right" (not trying to be partisan- just seems that goals are aligned in this respect from what I've read) hypermasculine feel. These online services and clinics appear to be popping up a lot

I never order testosterone levels (unless I'm expecting steroid mania/psychosis but we rarely see that), and when patients bring this up to me I generally direct them to discuss this with their PCPs while noting that as far as I'm aware this hasn't been rigorously studied, which then leads into the doctor-favorite discussion "but I read on whatever site..."

I'm guessing a lot of you all (esp in private practice) get asked this- it doesn't look like there's any actual evidence for this, so I'm just wondering how you communicate in an authoritative, non derisive manner...

Thanks!

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[cpants]

Not really understanding your question. How do you handle people with normal testosterone who want you to prescribe testosterone replacement? I just tell them that their levels are normal and that I won't be prescribing any steroids. Go back to PCP with fatigue, weight gain, etc.

I disagree that it hasn't been very well studied. Testosterone replacement can improve symptoms for patients with symptomatic hypogonadism. They have to have a low T and also have symptoms typical of hypgonadism (severe fatigue, low libido, etc.). Normal T - no replacement. Asymptomatic - no replacement. The only tricky cases are when they are right on the borderline of low--in which case we usually do a 3-6 month trial of replacement to midnormal range 400-600 and then reassess symptoms. In all of these cases, I explain and document very thoroughly my discussion of the risks of T replacement.

 

[DoctwoB]

Hi all- I couldn't find a thread on this anywhere, so I'd figure I would ask

I'm currently a psychiatry resident, and I have had several patients inquire about testosterone replacement/optimization, normal levels notwithstanding. This seems to be sort of fad-sh (but based on epidemiological evidence that avg male testosterone levels are decreasing) with a sort of "alt-right" (not trying to be partisan- just seems that goals are aligned in this respect from what I've read) hypermasculine feel. These online services and clinics appear to be popping up a lot

I never order testosterone levels (unless I'm expecting steroid mania/psychosis but we rarely see that), and when patients bring this up to me I generally direct them to discuss this with their PCPs while noting that as far as I'm aware this hasn't been rigorously studied, which then leads into the doctor-favorite discussion "but I read on whatever site..."

I'm guessing a lot of you all (esp in private practice) get asked this- it doesn't look like there's any actual evidence for this, so I'm just wondering how you communicate in an authoritative, non derisive manner...

Thanks!

Agree with cpants. Would you prescribe Synthroid to euthyroid patient? like mild hypothyroidism, hypogonadism has vague, non-specific, and very common symptoms. If a patient has a normal T level you have no business giving them exogenous hormone therapy. Granted T management is made a little trickier by inconsistent definitions of the low threshold and circadian variation, but the principles are still the same. Like any hormone therapy, testosterone has side effects including potentially increased risk of MI/CVA (controversy too much to go into here).

 

[dr zaius]

I think what he's getting at are the shops that are marketing hard for testosterone replacement in inappropriate candidates. I have seen clips from multiple places where they advocate for treating patients with low-normal levels or even what we would all consider completely normal. These are typically for-profit private places that advertise aggressively. I've had patients come in with T in the 700s demanding replacement citing various websites.

I agree with cpants' assessment, though. There is certainly an art to testosterone replacement, and even well meaning primary care docs get it wrong. I've ended up with patients referred over after being on replacement for a year or more with ridiculous hematocrits and a normal T value inciting the initial treatment. In my opinion it should all be handled by endocrine or us unless you've had significant experience with a knowledgeable physician. Just my 2 cents.

 

[cpants]

I think what he's getting at are the shops that are marketing hard for testosterone replacement in inappropriate candidates. I have seen clips from multiple places where they advocate for treating patients with low-normal levels or even what we would all consider completely normal. These are typically for-profit private places that advertise aggressively. I've had patients come in with T in the 700s demanding replacement citing various websites.

I agree with cpants' assessment, though. There is certainly an art to testosterone replacement, and even well meaning primary care docs get it wrong. I've ended up with patients referred over after being on replacement for a year or more with ridiculous hematocrits and a normal T value inciting the initial treatment. In my opinion it should all be handled by endocrine or us unless you've had significant experience with a knowledgeable physician. Just my 2 cents.

Don't forget the infertility consults--have seen a lot of those recently for guys in their 30s and 40s on T. Really? This can cause infertility? No one told me that. Sad when they had normal T and probably normal fertility to begin with. First do no harm...

 

[dr zaius]

Don't forget the infertility consults--have seen a lot of those recently for guys in their 30s and 40s on T. Really? This can cause infertility? No one told me that. Sad when they had normal T and probably normal fertility to begin with. First do no harm...

Hah! That's always a fun conversation to have with the patient. It's difficult not to throw the other doctor under the bus. The infertility guy here is nearing the end of his career and is pretty blunt about it to the patient...which is hilarious.