The decision of whether to go on hormone replacement therapy—whether estrogen, testosterone or any of the other choices available to both men and women—is perhaps the most personal and difficult medical choice many people will ever make. That’s largely because of how the HRT options have been shadowed by questions that are more cultural than medical.
HRT for women comes with a long history of controversy and disagreement within the medical community—much of it, as I’ve written previously, the result of simplistic misinterpretations of scientific data by physicians who are only now coming to see how heavily the evidence weights in favor of the benefits.
With men, it’s something different. The idea of average guys replacing hormones—testosterone, most commonly—has become more and more mainstream at a time when men they admire have been under intense scrutiny for just that. I’m talking about athletes. The problem is this is really two distinct conversations that sometimes blur into one. That’s unfair and unhelpful to anyone who likes to make decisions about their personal health based on science and not spin.
I don’t know that I’ve ever seen a better example of this sort of muddied perspective than an article on the front page of this week’s Sunday Review section of The New York Times about the burgeoning popularity of testosterone replacement in middle-aged and older men.
The article was by Steve Kettmann, a sports journalist who has written extensively about the performance-enhancement scandals of the past decade, primarily in Major League Baseball. Kettmann ghost wrote retired Oakland A’s outfielder Jose Canseco’s 2005 book, “Juiced.” And he posits that the steroid era in sports has led American culture “to the cusp of an Age of Juicing” by everyone from Hollywood actors to your next-door neighbor who just wants to feel the way he used to. Kettmann cited statistics showing that testosterone prescriptions in the U.S. went from 1.75 million a year to 4.5 million between 2002 and 2010.
The article was headlined: “Are We Not Man Enough?”
“What’s behind this explosion?” Kettmann wrote. “A change in medical opinion, for one thing. New research has cast doubt on claims that low-level testosterone supplements pose a health risk for men, specifically regarding links between prostate cancer and high testosterone levels.”
He’s right about that—there’s undeniable scientific evidence that replacing diminished levels of testosterone has a host of benefits—from mood and memory to physical stamina—with minimal demonstrated risk. Still, the notorious doping scandals on the sports pages have confused the issue. Remember Barry Bonds getting so big that people referred to him as “Michelin Man”? Bonds and other athletes caught juicing were taking anabolic steroids, and in vastly higher doses than even the highest physiologic ones we give in age management medicine to patients who choose to include them in their hormone therapy. (It also takes intensive weight lifting to achieve the level of muscular development these athletes have.)
Kettmann acknowledged the obvious difference “between sluggers shooting themselves up to reach testosterone levels 50 times above normal — consequences be damned — and low-level supplements that can improve quality of life with a minimum of health risk.”
But he worried that a version of the pro athletes’ mentality —ballplayers feeling pressured to do whatever’s necessary to compete at that high level and stay in the game—could be creeping into everyday culture. “Might not the ‘low T’ mind-set push men to juice up, even if a little slowing down with age might in fact be natural?” he asked.
Here’s my answer to that: Slowing down with age is not natural in the same way that growing up from birth to early adulthood is. The core principle of age management medicine is that Mother Nature has no particular—i.e. natural—plan for how we age. It’s not that men are “supposed” to feel less than themselves when their testosterone declines. Just as women are not programmed to get—and must accept as “natural”—the hot flashes and mental fogginess that comes with menopause. We are simply living beyond our warranty . So it makes no sense to argue that using safe, accepted, available methods of rejuvenation is somehow tinkering with nature’s grand plan. Because nature has no grand plan after peak reproductive age (25-30) and we’ve passed along our genes. (More about the age management approach.)
vs. Life Enhancement
Kettmann interviewed Dr. Abraham Morgentaler, an associate clinical professor of urology at Harvard Medical School and author of the book “Testosterone for Life.” Dr. Morgentaler said he was once a testosterone skeptic but that he’d come to see that, in fact, “There are still millions of men in this country who have symptoms and signs of testosterone deficiency who are not diagnosed or treated and should be.”
In good part, said Dr. Morgentaler, this is because of the casual stigma created by the sports scandals. “People have the idea that stuff is illicit and illegal and dangerous,” he told Kettmann. “But really the story in sports is that it’s against the rules of whatever game it is.”
Apparently, Kettmann thinks maybe it’s not just sports that should have rules against hormones. To Dr. Morgentaler’s experience of treating men in the corporate world whose low testosterone had cost them their once burning drive, Kettmann responds oddly: By suggesting, essentially, that a man’s diminished testosterone might be good for society at large. “Do we really want to feed a business culture that increasingly elevates cocksure confidence and pushiness above all else, especially if it filters into everyday life?”
This led Kettmann to the inevitable Wall Street-testosterone connection. “In an era marked by the dangerous decisions of an entire industry full of gung-ho alpha males, shouldn’t we be wary of a culture that pushes us even further in that direction? Maybe some quiet time for reflection or awareness of the consequences of one’s actions might not be so bad — even if it means a little lower T.”
Well, that sure does miss the point—of both the benefits of testosterone and the lessons of Wall Street. In fact, it seems to come perilously close to some kind of reverse eugenics philosophy. Replacing testosterone in an aging executive doesn’t make him a “cocksure” and “pushy” businessman so much as it prevents him from making poor decisions or none at all because of his low mood and lack of the self-confidence that helped him succeed in the first place. It’s a complete mischaracterization of the cognitive and emotional effects of physiologic testosterone replacement therapy on the aging male.
The association of brash action with high testosterone levels comes from adolescents who don’t yet have fully developed frontal lobes to control their impulses. Instead of blaming the transgressions that brought about the 2008 financial crisis on the testosterone levels of grown men with fully developed frontal lobes, how about we stick to things like old-fashioned greed?
A patient’s wife told me that her CEO husband’s company was on the brink of disaster because he no longer had “the balls” to make the kinds of tough decisions necessary to put his business back on course. By Kettmann’s logic, is he suggesting that aging men whose testosterone levels are not declining should be castrated? (And maybe even younger men, while we’re at it). Of course he’s not. But it just shows you how astray people can go when they start applying their particular views of society and culture (which are their right to have, of course) to other people’s decisions about their own health.
Interestingly, our cultural zeitgeist has no problem with a far more pervasive use of hormones that are actually classified as steroid: the millions of women, including teenagers and now even tweens (because of the earlier puberty we’re seeing), taking hormonal contraceptives. For decades now, women have made a lifestyle choice of postponing pregnancy until their thirties and sometimes early forties through the use of hormones, non-biodentical ones, in dosages that are considerably higher than what occurs naturally in their bodies. It’s in the service of their careers, a perfectly legitimate choice. But if it’s not an issue for a career-minded woman of 25, why is it one for a man of 50 who wants to use a much smaller, physiologic dosage of a bioidentical hormone to continue to function well at his career?
The irony is that one of the major side effects of oral contraceptives is to lower a woman’s effective testosterone level, possibly making her a little more passive—and less competitive—in the workplace. JMR