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In light the controversial studies linking testosterone replacement therapy to cardiovascular risks, three urologists discuss how their approach to prescribing TRT has (or hasn't) changed.
Dr. Anderson“I don’t have many men with low testosterone in my practice, but the risks of testosterone that I take more into account are the more classic ones, like worsening BPH, sleep apnea, and considering carefully whether to supplement somebody who has a history of prostate cancer.
Those factors are contraindications to a person who has a lot of obstructive voiding symptoms and severe sleep apnea. The controversy has been resolved fairly well with regard to whether somebody whose prostate cancer has been treated and with no biochemical activity can be supplemented. The answer is yes, as long as they understand the issues and potential risk.
I haven’t had to deal with the idea of increased risk of heart attack, however. I don’t have older men who are on testosterone; my practice doesn’t really include the men covered in the studies. If I had an older man who fell into that category, I would look into the studies more. Talking about supplementing low testosterone to the normal range, I would look at the study to see why both would seem to be bad, because there are heart risks with low testosterone, too. I would look into it more carefully than I’ve had to right now.”
Gregory Anderson, MD
Dr. Broderick“The studies they’re talking about-the PLOS ONE study (2014; 9:e85805) and the VA study in JAMA (2013; 310:1829-36)-weren’t looking at prospective, controlled trials. They looked for some signal that a patient had had testosterone; in one study, that a code had been written for low T and a prescription given. They looked at whether a patient came back to the medical institution with cardiovascular symptoms in the subsequent 6 to 12 months.
We lack prospective studies. We’re looking at retrospective information. Now, one study published in May by the American Association of Clinical Endocrinologists looked at 19,000 men on appropriate treatment; those men had no higher risk of a stroke or heart attack than the average community dweller in a matched group. So there’s data on either side of the seesaw to support either conclusion. There is data to suggest testosterone can be cardioprotective and data to suggest testosterone may trigger a symptomatic event.
If a patient’s symptoms coincide with low-level testosterone and he doesn’t have risk factors for testosterone supplementation, I offer him that. Then I follow good FDA guidance, and within the first 2 weeks, get a level. I start the patient at the lowest dosage. If his testosterone springs into the mid-range of 400-500 ng/dL I leave him there and reassess twice a year. Testosterone repletion and therapy is not as simple as TV commercials make it out to be.
Screening in the urologist’s office for cardiovascular disease is a matter of asking simple, straightforward questions about cardiovascular risk. If they answer ‘no’ to all the questions, you can check that off your worry list.”
Gregory Broderick, MD
“I have a lot of conversations, as you normally do with any topic that is at all controversial, about the pros and cons of testosterone therapy. Various studies show that hypogonadal men have an increased risk of heart disease. But the studies were controversial, and other studies have indicated the opposite. I present both sides of the story. I tell men that, ultimately, it’s like any other treatment; there’s risk in anything we do or don’t do. If they want to proceed, great.
I tell them they have to be monitored. If they have any factors that put them at risk for heart disease, such as smoking, they need to follow up with their primary care physician, stop smoking, and exercise.
About 90% of the people continue to use it, appropriately. I’ve had very few people back away once I’ve given them the pro and the cons. Some people get gun-shy, and if they are, that’s fine.
This is the way I’ve always handled issues, but clearly discussion has increased in the past months. I’ve seen a lot of primary care doctors who were giving testosterone replacement get out of it. They say, ‘Go see the urologist.’ In some ways, we’re seeing more patients because of these reports.”
Kevin Perry, MD
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