Behind the Scenes: The Making of Low T

It's seems near impossible these days to pick up a magazine, listen to the radio, watch the television or drive without seeing a billboard plastered with some message related to testosterone.  Just where and how did this condition (disease?) come into being?  After all, hasn't low testosterone been around since men lived long enough to reach a point in their lives when levels dropped significantly?  So why all the press now?  Perhaps, it's partially due to the Baby Boomers reaching that very point in their collective lives since they're not about to go without a fight!  Or perhaps it's due in part to Big Pharm doing its research and developing new products that need larger markets.

On a more personal level, I was recruited out of academia a decade ago to assist a private practice in growing but more importantly in giving it the research gravitas to support its attempt to corner the market on hormone deficiencies and even suboptimal hormonal levels.  And so I tried to get my hands on as much peer-reviewed research as possible.  Unfortunately, most of it was observational in nature, albeit over half a dozen observational studies all conclude that low testosterone is associated w/higher mortality no matter which population was studied, whether American (3 different cohorts), Italian, British or Scandanavian.  Granted, there were randomized controlled trials demonstrating benefit from testosterone replacement/supplementation, but it was rarely w/o risk, and there were a few w/o any benefit at all.  

Which then leaves us w/consensus statements by "thought leaders".  Little did I know that many of these "guidelines" have been ghost-written by others as revealed in a special article published early online in JAMA Internal Medicine.  So is low T real?  Most definitely yes, but most likely not in a high enough percentage of men to warrant dramatically raising rates of testosterone prescriptions over the last decade.  So what are we to do?  As a clinician, let's not jump directly on the hypogonadism/andropause band wagon.  

Instead, let's look for other reasons that might explain the vague symptoms that overlap with so many other issues & conditions.  Stress to the relationship, family, friends, money, job security, etc.  What about poor lifestyle choices such as smoking and/or drinking to excess?  Any health conditions or diseases that predispose someone to loss of energy, obesity, decrease in libido, depression?  Anemia?  Diabetes?  Hypothyroidism?  How about (new) medications?  In other words, don't attempt to jump on the low T bandwagon w/o a thorough evaluation by your family doc.  And if you do decide to go for a test drive, so to speak, remember that testosterone replacement/supplementation/optimization is not a do-it-yourself project. 

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