Studies find many men who need testosterone do not get treated after diagnosis

This review shows how poorly managed many men diagnosed with low testosterone are. Is testosterone the problem or are ill-educated doctors the real problem?

Characteristics of Men Undergoing Testosterone Replacement Therapy and Adherence to Follow-up Recommendations in Metropolitan Multicenter Health Care System

Urology, April 7, 2015 (online access)

Objective

To identify the frequencies of treatment and recommended laboratory follow-up for men with low serum testosterone levels.

Methods

The Electronic Data Warehouse was queried to identify men of ages 18-85 years, who obtained a testing for serum total testosterone level from 2009 to 2012. The frequency of testosterone replacement therapy (TRT), patient demographics, and clinical characteristics were collected. The frequency of follow-up with serum total testosterone and complete blood count levels was documented.

Results

Among 9176 men who underwent testing for low testosterone levels, 3320 (36%) of them were hypogonadal with a mean serum total testosterone level of 194.3 ± 64.9 ng/dL. Of them, 17.7% men were treated with TRTs. The treatment frequency significantly increased from 8.3% in 2009 to 24% in 2012. A total of 4.8% of men of reproductive ages (age, 18-35 years) were placed on TRTs. Within 180 days of initial testing, only 40% of treated men received follow-up with liver function tests and/or complete blood count, and only 49% had a follow-up serum testosterone level.


Conclusion

Although the frequency of TRT is increasing, only a small percentage of hypogonadal men are actively undergoing treatment. A significant proportion of men of reproductive age are being treated with significant impacts on potential fertility. Less than half of the patients treated are being monitored appropriately after testosterone replacement. This highlights the importance of further education for providers prescribing testosterone replacement.

Many doctors are not doing a good job at monitoring TRT as found by this study.


Baillargeon J, Urban RJ, Kuo YF, Holmes HM, Raji MA, et al. Screening and monitoring in men prescribed testosterone therapy in the U.S., 2001-2010. Public Health Rep. 2015;130(2):143-52. http://www.ncbi.nlm.nih.gov/pubmed/25729103


OBJECTIVES: The Endocrine Society recommends testosterone therapy only in men with low serum testosterone levels, consistent symptoms of hypogonadism, and no signs of prostate cancer. We assessed screening and monitoring patterns in men receiving testosterone therapy in the U.S.


METHODS: We conducted a retrospective cohort study of 61,474 men aged >/=40 years, and with data available in one of the nation's largest commercial insurance databases, who received at least one prescription for testosterone therapy from 2001 to 2010.


RESULTS: In the 12 months before initiating treatment, 73.4% of male testosterone users received a serum testosterone test and 60.7% received a prostate-specific antigen (PSA) test. Among men who were tested, 19.5% did not meet Endocrine Society guidelines for low testosterone. In the 12 months after initiating treatment, 52.4% received a serum testosterone test and 43.3% received a PSA test. Multivariable analyses showed that those seen by either an endocrinologist or urologist were more likely to receive appropriate tests.


CONCLUSIONS: A substantial number of men prescribed testosterone therapy did not receive testosterone or PSA testing before or after initiating treatment. In addition, almost one out of five treated men had baseline serum testosterone values above the threshold defined as normal by the Endocrine Society. Men treated by endocrinologists and urologists were more likely to have been treated according to guideline recommendations than men treated by other specialties, including primary care.

This is a press release that describes issues with a previous study from the veterans administration hospital that also fails to monitor hematocrit and estradiol (and in which the majority of veterans were not monitored after starting testosterone). When will large medical groups get it?

ExcelMale.com Identifies Major Flaws in Recently Published VA Testosterone Study





A men's health grassroots and education group advocates for better testosterone replacement therapy of veterans of the U.S. Armed Forces


Houston, TX -- (SBWIRE) -- 11/14/2013 -- Last week's Journal of American Medical Association (JAMA) published a retrospective study (1) that was performed at the Veteran's Administration (VA) hospital system. While it has long been known that testosterone replacement therapy (TRT) improves sexual function, bone density, lean body mass, and lipids, this study concluded that testosterone therapy may increase the risk of cardiovascular problems in men with a history of heart disease. It cautioned that men with pre-existing cardiovascular problems and testosterone deficiency should avoid TRT. ExcelMale.com, an education website for men, identified major flaws in this study that wrongly alarmed patients, physicians and the media.

While it is commendable that the VA hospital system collected data on the use of testosterone in over 8,000 veterans with cardiovascular disease, the study highlights deficiencies in the hospital system's testosterone management protocol.

The VA study showed that 40% of patients did not have their testosterone blood levels retested after they started testosterone. This lack of follow up contradicts a review of guidelines published on 2011 by the American College of Cardiology Foundation that The Endocrine Society, the American Association of Clinical Endocrinologists, the American Society of Reproductive Medicine, and the European Association of Urology recommendations of monitoring patients' blood analysis 3 months after initiation of testosterone therapy (2) to determine TRT dose adjustments and potential side effects.

A previously study (3) also published in JAMA in 2009 showed that men with total testosterone blood levels below 550 ng/dl had a significant increase in their risk of cardiovascular disease, while men with levels above 550 ng/dl reduced their risk by 30%. Monitored participants in the VA study were only able to increase their total testosterone blood levels to 332 ng/dl, a value considered sub-optimal by all testosterone treatment medical guidelines.

Another shortcoming of the VA hospital system's TRT protocol highlighted by the study is the lack of monitoring and managing of hematocrit (red cell volume) and estradiol (a female hormone produced in the body from testosterone). TRT can increase hematocrit and estradiol is a minority of men resulting in increased blood viscosity and cardiovascular risks as documented in the previously mentioned 2009 JAMA study (4). Fortunately, both variables can be easily managed if patients are properly monitored.

The majority of participants in the VA study used testosterone patches. Once a popular method of testosterone delivery, testosterone patches are no longer used due to their poor absorption and inconvenience. This is reflected in the VA study where most of the participants continued to have testosterone deficiency and increased cardiovascular risk.

"Publishing flawed studies only increases the current misconceptions surrounding this important therapy and unnecessarily alarms TRT patients and their physicians", said Nelson Vergel, founder of ExcelMale.com. "We encourage patients, physicians and the media to closely examine studies for misleading information that could increase barriers to life saving therapies", added Vergel.

"We urge the VA hospital system to revise their TRT protocol and to follow current testosterone guidelines. We want only the best for the men who have served our country", said Keith Willse, co-founder of ExcelMale.com.

ExcelMale.com is a peer reviewed and moderated safe platform where men can privately and securely share information and experiences about health and productivity. It is moderated daily for content and enforcement of a code of conduct and provides well organized archives of articles, forum chats, product reviews, and videos related to:

- Testosterone replacement,
- erectile dysfunction and sex drive,
- fat loss and muscle gain,
- energy boosters,
- exercise,
- nutrition,
- supplementation,
- diagnostics,
- pharmaceuticals,
- and all things related to men's health and productivity.

For more information and patient/clinician education on testosterone, visithttp://www.ExcelMale.com

References:

1- JAMA. 2013;310(17):1829-1836.
2- J Am Coll Cardiol. 2011;58(16):1674-1681.
3- JAMA. 2009 May 13;301(18):1892-901.
4- JAMA. 2009 May 13;301(18):1892-901.

The VA regularly monitors my hematocrit, but does not, most likely cannot, monitor my E2. Doctors there cannot unilaterally order tests that the system does to allow. I have to see a private Dr for the more esoteric labs.

Sakuraba39 said:

The VA regularly monitors my hematocrit, but does not, most likely cannot, monitor my E2. Doctors there cannot unilaterally order tests that the system does to allow. I have to see a private Dr for the more esoteric labs.

Click to expand...

It's sad the VA would consider it "esoteric" when the data clearly shows the benefits of that (and other tests they don't do...) of properly managed E2 in men on TRT or not.