A man's testosterone (T) levels begin to decline in their late twenties. As these levels decrease, men may experience both physical and emotional changes. Today, the prevalence of toxin exposure, particularly to xenoestrogens—natural and artificial estrogen mimickers that act as endocrine disruptors—has contributed to this issue. Common sources of xenoestrogens include soy products, plastics, herbicides, pesticides, and personal care products. As a result, testosterone levels among men are at an all-time low, and many young men in their 20s and 30s are facing the side effects of low testosterone (low T).
Common side effects of low T:
Decreased muscle mass
Decreased strength
Increased insulin resistance
Increased visceral fat
Increased risk of heart disease
Increased risk of diabetes
Decreased libido
Erectile dysfunction
Low energy
Lack of motivation
Increased adiposity (fat accumulation)
Depression/anxiety
Testosterone replacement therapy (TRT) is a standard treatment for men with hypogonadism, or low T, because it is very effective in alleviating and sometimes completely resolving the symptoms associated with low T. Unfortunately, many healthcare providers mistakenly believe there is a link between testosterone, benign prostatic hyperplasia (BPH), and worsening lower urinary tract symptoms (LUTS). Furthermore, when an allopathic provider does prescribe testosterone, the dosage is often too low to be efficacious, overlooking a man's symptoms and, consequently, his 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 a warning about the risks associated with testosterone therapy, including worsened BPH, potential risks of prostate cancer, and an increase in prostate-specific antigen (PSA) levels. However, contrary to this warning, testosterone therapy appears to be beneficial in preventing BPH and LUTS (Saad, 2007; Yassin et al., 2014). Furthermore, most research indicates that there is little to no evidence suggesting that men receiving testosterone treatment face higher risks for BPH and its related symptoms (Reynaud et al., 2015). In a randomized controlled trial involving 44 men with late-onset hypogonadism, Marks et al. (2006) found that those treated with TRT did not significantly increase testosterone or dihydrotestosterone (DHT) levels in prostate tissue or cause gene alterations despite having significantly elevated serum testosterone levels.
Some researchers assert that the long-held belief linking prostatic growth to serum testosterone levels stems from a 1941 study by Charles Huggins and Clarence Hodges. This pivotal study demonstrated that castration led to the regression of prostate cancer, while testosterone administration resulted in prostate growth. Notably, this study included only one subject, a patient who already had prostate cancer at the beginning of the research.
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, despite their higher T levels, younger men do not see magnified prostatic growth (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).
Bass & Kohler (2016)
According to Kathrins et al. (2015), a systematic review of literature conducted from 1994 to 2015, which included 35 trials, found no causal relationship between TRT, new or worsening LUTS, and prostate volume. Furthermore, the researchers did not identify high-quality evidence to support the recommendation that TRT is contraindicated in men with severe LUTS.
Additionally, a significant number of hypogonadal men tend to become overweight, obese, and insulin resistant, which increases their risk of developing type 2 diabetes and cardiovascular disease (Wang et al., 2011; Saad et al., 2012; Corona et al., 2011; Traish et al., 2009). TRT has the potential to mitigate these serious health risks. Several studies involving hypogonadal men treated with testosterone have shown increases in muscle mass, significant reductions in fat mass, lower serum low-density lipoprotein (LDL) levels, and improvements in blood pressure and heart rate (Yassin & Doros, 2013).
Informed consent is both an ethical and legal obligation for medical practitioners in the United States, stemming from a patient's right to make decisions about their own body. This process requires healthcare providers to educate patients about the risks, benefits, and alternatives to various interventions, such as medications and surgeries. The American Medical Association's Code of Ethics emphasizes that "successful communication in the patient-physician relationship fosters trust and supports shared decision-making." Over the past two years, how frequently have physicians and other medical professionals violated the AMA's Code of Ethics?
While the FDA has issued warnings regarding TRT without high-level evidence to support their stance, patients should still be cautioned about the potential worsening of LUTS when considering treatment. It is also essential to inform patients about evidence suggesting that testosterone does not contribute to benign prostatic hyperplasia (BPH) and may play a significant role in improving BPH/LUTS. Additionally, as men age, they should be aware of the risks associated with declining testosterone levels, which include insulin resistance, diabetes, heart disease, reduced libido, erectile dysfunction, fatigue, decreased strength, reduced muscle mass, frailty, and depression.
If one thinks they have a testosterone deficiency, it is essential to discuss their physical and mental symptoms with a certified provider in advanced bioidentical hormone replacement therapy, 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.
Michael Furci is a Certified Nurse Practitioner.
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References
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 of 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.
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