We have all seen the advertisement. An ex-ballplayer, a Hall of Famer, is approached by a couple of pretty women in the gym. They comment on how muscular the player is, that he hasn’t changed a bit since his playing days. They inquire, “How do you do it?” The player then launches into his pitch. His supplement keeps him fit and virile due to its “man-boosting” properties. What are these “man- boosting” properties? Can it help boost the heart muscle as well?
The “man-booster” is the male sex hormone testosterone (T). T is responsible for normal sperm production, maturation of the male sex organs, growth of the beard and pubic hair and deepening of the voice. In addition, T increases muscle mass and strength and helps with bone density. Low T is a syndrome where T is not secreted in sufficient amounts. Low T may be caused by radiation, trauma, mumps and medications (such as opioids and steroids like prednisone). In addition, levels of T decline as men get older. About 25% of men over 65 will have Low T while 54% of hospitalized patients and 50% of diabetics have Low T. The condition is diagnosed by checking levels of T in the blood. Levels are drawn on two separate mornings before 10 AM (T levels drop after 10 to 11 AM). Total T and free T are measured, with free T the more accurate test. Symptoms of Low T include hot flashes, decreased libido, depression, fatigue, erectile dysfunction and reduced muscle mass. In addition, there is a relationship between Low T and blockages in the heart arteries as well as heart attacks and cardiac deaths. Many studies have shown lower levels of T in men with significant blockage in the heart arteries, especially when those blockages occur at younger ages (45 years old or younger). However it is unclear whether Low T causes the blockages or whether the Low T is just a marker of poor overall health.
There are several different ways to replace T in patients with Low T. A patch containing T can be applied to the skin. This isn’t used much as the patch is very irritating and can cause a rash. A gel with T can be applied to the skin. T may also be injected into the muscles. Oral T replacement (a pill or tablet) is not recommended as it can cause liver toxicity (injection and skin application bypass the liver and are safer). Regardless of the formulation used, the goal of T replacement is to restore T levels in the blood to normal and reverse the symptoms of Low T. T replacement has been shown to improve libido but it is less effective at improving mood and depression. Fatigue and vigor improve with T replacement. In addition, there is a decrease in fat, and an increase muscle mass and strength. Lastly, T replacement reduces blood sugar and triglycerides with no significant improvement in cholesterol and blood pressure. There are serious side effects with T replacement. The prostate increases in size under the stimulation of T, which can lead to difficulty urinating. T replacement can trigger prostate cancer to grow. Before being placed on T, screening for prostate cancer should be performed either with an examination of the prostate or a blood test (PSA). T replacement may make sleep apnea worse. Lastly, T replacement may cause blood clots in the legs.
Since most studies have shown that Low T is associated with heart disease, what is the role for T replacement in the cardiac patient? Unfortunately, the answer is not clear. Many studies have shown an increased rate of cardiovascular events in those taking T replacement. However, there are an equal number of studies showing the opposite; that T replacement can decrease the risk for a heart attack. There are no high quality studies looking at T replacement and cardiac outcomes as the primary endpoint. Therefore, at the present time, the issue of cardiovascular safety in T replacement is controversial. One area where T replacement may be beneficial is congestive heart failure. Although the heart’s pumping ability (ejection fraction) was not improved on T replacement, patients on T replacement could exercise more, have less shortness of breath and did not have an increase in heart attack or death.
Due to aggressive advertising, marketing and celebrity pitches, there seems to be an epidemic of Low T, but who should be treated? The bottom line is that young men with low levels of T in the blood and with symptoms of Low T should be offered T replacement. Symptoms should be significant; just having fatigue is not enough to warrant T replacement. While on therapy, these patients need careful surveillance to make sure they don’t develop prostate cancer or any of the other side effects of T replacement. The use of T replacement in older men and those with heart disease is still controversial and those patients should be counseled about the potential cardiac side effects. Those with recent heart attack, heart stent, or stroke likely should avoid T replacement, given the uncertainty of the risk.
If you are interested in participating in a study examining Low T and heart disease, please call the Medicor Cardiology research department at 908-243-5009 to see if you qualify.
