A new testosterone study from Shalender Bhasin published in the New England Journal was halted early because the testosterone treated group had more heart attacks.
Doctors gave topical testosterone to obese, elderly, immobilized men with underlying heart disease. All had limitations in mobility, defined as having difficulty walking two blocks or climbing steps. About half were obese, and 75% were heavy smokers. More than 50% had pre-existing heart disease. Almost all had hypertension. A quarter were diabetics. 60% were on statin drugs like Lipitor. Men younger than 65 were excluded and the average age was 74.
Starting testosterone levels were low, averaging 250 ng/dl for Total and 48 for Free. After treatment with 5 to 15 grams/day of topical testosterone gel (testim or androgel), levels were 574 ng per dl (after adjustment of the dose) and 292 ng/dl in the placebo group. As you might expect, the Testosterone Group had significant improvements in leg muscle strength.
Sending Old Men Up the Hill
If we recruited a group of immobilized, obese, elderly frail men with heart disease, and then instructed them to run up a mountain hill, these men would be unable to go more than a few steps, and no harm would come from it. However, if we took this same group of men, apply testosterone gel for a few weeks, as Bhasin did, and then send them up the hill, this would be a bad thing. The testosterone would give the men the leg muscle strength to run up the hill and many would succumb to heart attacks. This is a nutshell is what happened in the Bhasin study.
Low Testosterone Associated with Increased Mortality
Three separate population studies have shown that low testosterone levels in men are associated with increased mortality from cardiovascular disease and all causes.
A recent study by Dr Chris Malkin published in Heart followed 900 men with angiographic demonstration of coronary artery disease over 8 years. The men with low testosterone had 22% mortality compared to only 12 % for men with normal testosterone levels. Thus, low testosterone was associated with a much higher mortality rate.
In addition, multiple studies have been done showing testosterone treatment reduces cardiac ischemia in men with known heart disease. For example, an elegant study by English et al. showed less cardiac ischemia in men treated with testosterone. Men with known heart disease were give a treadmill test, and their Electrocardiogram (EKG) observed while walking up an inclined treadmill. Given enough time on the treadmill, the heart disease shows up as EKG changes and chest pain. The doctors will then stop the test and allow the man to rest. The testosterone group showed longer times on the treadmill before reaching chest pain or critical EKG changes. This indicates improved blood flow with testosterone. However, the men still reach chest pain and critical EKG changes and must be taken off the treadmill. Continuing would bring on a heart attack.
Imagine what would happen if the doctors allowed the men to keep going, to continue up the inclined treadmill in spite of the chest pain? As you might guess, this is an excellent technique for causing heart attacks, and is not advisable. This scenario explains why the men in the Bhasin Study had more heart attacks on testosterone. The testosterone gave them the strength to continue up the hill with severe underlying heart disease that caused a heart attack in some of the men.
Testosterone Benefits For Heart Failure Patients
Dr Malkin published a study showing improved cardiac functional capacity in men with heart failure. Similarly, a study from Italy found testosterone beneficial for women with heart failure, as well.
A more reasonable approach for testosterone replacement is described by Morgentaler in his 2007 commentary, “Guidelines for Male Testosterone Therapy: A Clinician’s Perspective.”
Abraham Morgentaler is a Harvard trained Urologist, who says he was taught in medical school that low testosterone was rare and treatment ineffective. Once he started clinical practice in 1988, he was surprised to find that many of his patients had low testosterone associated with erectile dysfunction (ED) which greatly improved with testosterone injections. Patients thanked him for finally “feeling normal again.” Nowadays in 2010, testosterone is accepted treatment for diminished libido and erectile dysfunction (ED). Dr Morgentaler actually prefers to start with transdermal gel testosterone before using the Viagra and Cialis type drugs, (the phosphodiesterase type-5 inhibitors PDE5i).
Risks of Testosterone Treatment Reviewed by Morgentaler
Dr Morgentaler 2004 NEJM article is also useful, covering the “Risks of testosterone-replacement therapy and recommendations for monitoring”. Dr Morgentaler says that 4 million men may be candidates for testosterone treatment, yet only 5 percent are actually treated. Even though there are no large scale, long term clinical studies looking at risks and adverse effects, the number of testosterone prescriptions have increased 500 percent since 1993.
In his 2004 report, Dr Morgentaler says that previous studies of testosterone-replacement have not shown increased of heart disease such as heart attacks, myocardial infarction, stroke, or angina. This is opposite to the findings of the Bhasin report. Increased blood count (Polycythemia) is an adverse effect noted in about 3% of men after testosterone treatment. This is controlled by reducing dosage or donating blood. Dr Morgentaler also discusses, prostate, PSA, sleep apnea, and other issues. He finds that testosterone treatment is not associated with increased prostate cancer, although he recommends prostate surveillance. Finally he discusses that a small percentage of men may note breast enlargement or tenderness from treatment. For more, take a look at Morgentaler’s 2009 book, Testosterone for Life.
Conclusion:
Testosterone therapy for immobilized elderly men with underlying chronic conditions such as obesity, heart disease, hypertension, and cigarette smoking is not recommended. However, for all other candidates for testosterone therapy, the health benefits clearly outweigh the risks and adverse effects which are quite manageable.
The full references to this article can be found at http://jeffreydach.com/2010/10/14/testosterone-causes-heart-attacks-by-jeffrey-dach-md.aspx
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