Nelson Vergel
Founder, ExcelMale.com
Testosterone Lab Testing and Initiation in the United Kingdom and the United States, 2000 to 2011
Scovell JM, Ramasamy R, Lipshultz LI. Re: Testosterone Lab Testing and Initiation in the United Kingdom and the United States, 2000 to 2011. European Urology 2015;66(4):786-7. http://www.sciencedirect.com/science/article/pii/S0302283814007404
Layton JB, Li D, Meier CR, et al. Testosterone Lab Testing and Initiation in the United Kingdom and the United States, 2000 to 2011. J Clin Endocrinol Metab 2014;99:835–42. http://press.endocrine.org/doi/full/10.1210/jc.2013-3570
Experts’ summary:
The retrospective cohort study by Layton and colleagues sought to describe the patterns of testosterone testing and testosterone prescriptions in men in the United Kingdom and the United States. The authors utilized data from general practitioner health care records in the United Kingdom and from both commercial and Medicare insurance claims in the United States between 2000 and 2011. This study found that testosterone testing rates increased in both countries and that new testing in untreated patients rose threefold in the United Kingdom and more than fourfold in the United States.
This study observed that a significant proportion of men in their reproductive years received testosterone supplementation. Men aged 18–39 yr accounted for a significant minority of new testosterone prescriptions (United Kingdom: 16%; United States: 12%), and a higher proportion of US men with normal or high serum testosterone levels received testosterone prescriptions (United Kingdom: 1%; United States: 4–9%).
This discrepancy in testing and diagnosis was also evident from the fact that in the United Kingdom, 88% of men who were prescribed testosterone were diagnosed with clinical or laboratory hypogonadism compared with only 60% of men in the United States.
Experts’ comments:
The study by Layton et al., using data from both UK and US cohorts, highlights the discrepancies between a definitive diagnosis of hypogonadism and interventional treatment. This study, along with an analysis performed by Baillargeon and colleagues [1], provides evidence for what we already see in clinical practice, namely, that the number of testosterone therapy prescriptions has risen dramatically over the past decade.
Because practitioners have become more aware of hypogonadism, we would hope to see an increase in laboratory testing but with a smaller increase in testosterone therapy.
These data, however, demonstrate an alarming trend.
A subset of patients are not receiving adequate testing [2] prior to initiation of testosterone therapy, and more men are being prescribed testosterone therapy despite no clinical or laboratory diagnosis of hypogonadism.
This study provides clear evidence that guidelines for testosterone therapy initiation are seldom followed, and in the United States, the lack of adherence to guidelines has led to an overabundance of potentially unnecessary testosterone prescriptions.
Another alarming trend highlighted in the study is that in both countries, >10% of men initiating testosterone therapy are within their reproductive years. Practitioners often, do not consider the inhibitory effect of exogenous testosterone on a male's reproductive potential. In fact, a 2010 survey of American Urological Association members found that up to 25% of urologists would prescribe testosterone therapy for idiopathic male infertility [3], suggesting that the impact on fertility often is not only ignored but also incorrectly understood.
A survey of Canadian men presenting at a male infertility clinic between 2008 and 2012 found that an alarming 39% of the men on testosterone therapy received the prescription from either an endocrinologist or a urologist [4]. This finding suggests that a large group of men desiring fertility are receiving testosterone supplementation from practitioners outside the fields of endocrinology or urology and that some endocrinologists or urologists are not appropriately considering the ramifications of exogenous testosterone on fertility.
The reported discrepancy between adequate testing and new testosterone prescriptions highlights the need for increased physician education and the proper management of these patients by practitioners trained in appropriately diagnosing and treating male hypogonadism.
References
[1] J. Baillargeon, R.J. Urban, K.J. Ottenbacher, K.S. Pierson, J.S. Goodwin. Trends in androgen prescribing in the United States, 2001 to 2011. JAMA Intern Med, 173 (2013), pp. 1465–1466. http://archinte.jamanetwork.com/article.aspx?articleid=1691925
[2] S. Bhasin, G.R. Cunningham, F.J. Hayes, et al. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab, 95 (2010), pp. 2536–2559. http://press.endocrine.org/doi/abs/10.1210/jc.2009-2354
[3] E.Y. Ko, K. Siddiqi, R.E. Brannigan, E.S. Sabanegh Jr. Empirical medical therapy for idiopathic male infertility: a survey of the American Urological Association. J Urol, 187 (2012), pp. 973–978. http://www.sciencedirect.com/science/article/pii/S0022534711054607
[4] M.K. Samplaski, Y. Loai, K. Wong, K.C. Lo, E.D. Grober, K.A. Jarvi. Testosterone use in the male infertility population: prescribing patterns and effects on semen and hormonal parameters. Fertil Steril, 101 (2014), pp. 64–69. http://www.sciencedirect.com/science/article/pii/S0015028213030537
Scovell JM, Ramasamy R, Lipshultz LI. Re: Testosterone Lab Testing and Initiation in the United Kingdom and the United States, 2000 to 2011. European Urology 2015;66(4):786-7. http://www.sciencedirect.com/science/article/pii/S0302283814007404
Layton JB, Li D, Meier CR, et al. Testosterone Lab Testing and Initiation in the United Kingdom and the United States, 2000 to 2011. J Clin Endocrinol Metab 2014;99:835–42. http://press.endocrine.org/doi/full/10.1210/jc.2013-3570
Experts’ summary:
The retrospective cohort study by Layton and colleagues sought to describe the patterns of testosterone testing and testosterone prescriptions in men in the United Kingdom and the United States. The authors utilized data from general practitioner health care records in the United Kingdom and from both commercial and Medicare insurance claims in the United States between 2000 and 2011. This study found that testosterone testing rates increased in both countries and that new testing in untreated patients rose threefold in the United Kingdom and more than fourfold in the United States.
This study observed that a significant proportion of men in their reproductive years received testosterone supplementation. Men aged 18–39 yr accounted for a significant minority of new testosterone prescriptions (United Kingdom: 16%; United States: 12%), and a higher proportion of US men with normal or high serum testosterone levels received testosterone prescriptions (United Kingdom: 1%; United States: 4–9%).
This discrepancy in testing and diagnosis was also evident from the fact that in the United Kingdom, 88% of men who were prescribed testosterone were diagnosed with clinical or laboratory hypogonadism compared with only 60% of men in the United States.
Experts’ comments:
The study by Layton et al., using data from both UK and US cohorts, highlights the discrepancies between a definitive diagnosis of hypogonadism and interventional treatment. This study, along with an analysis performed by Baillargeon and colleagues [1], provides evidence for what we already see in clinical practice, namely, that the number of testosterone therapy prescriptions has risen dramatically over the past decade.
Because practitioners have become more aware of hypogonadism, we would hope to see an increase in laboratory testing but with a smaller increase in testosterone therapy.
These data, however, demonstrate an alarming trend.
A subset of patients are not receiving adequate testing [2] prior to initiation of testosterone therapy, and more men are being prescribed testosterone therapy despite no clinical or laboratory diagnosis of hypogonadism.
This study provides clear evidence that guidelines for testosterone therapy initiation are seldom followed, and in the United States, the lack of adherence to guidelines has led to an overabundance of potentially unnecessary testosterone prescriptions.
Another alarming trend highlighted in the study is that in both countries, >10% of men initiating testosterone therapy are within their reproductive years. Practitioners often, do not consider the inhibitory effect of exogenous testosterone on a male's reproductive potential. In fact, a 2010 survey of American Urological Association members found that up to 25% of urologists would prescribe testosterone therapy for idiopathic male infertility [3], suggesting that the impact on fertility often is not only ignored but also incorrectly understood.
A survey of Canadian men presenting at a male infertility clinic between 2008 and 2012 found that an alarming 39% of the men on testosterone therapy received the prescription from either an endocrinologist or a urologist [4]. This finding suggests that a large group of men desiring fertility are receiving testosterone supplementation from practitioners outside the fields of endocrinology or urology and that some endocrinologists or urologists are not appropriately considering the ramifications of exogenous testosterone on fertility.
The reported discrepancy between adequate testing and new testosterone prescriptions highlights the need for increased physician education and the proper management of these patients by practitioners trained in appropriately diagnosing and treating male hypogonadism.
References
[1] J. Baillargeon, R.J. Urban, K.J. Ottenbacher, K.S. Pierson, J.S. Goodwin. Trends in androgen prescribing in the United States, 2001 to 2011. JAMA Intern Med, 173 (2013), pp. 1465–1466. http://archinte.jamanetwork.com/article.aspx?articleid=1691925
[2] S. Bhasin, G.R. Cunningham, F.J. Hayes, et al. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab, 95 (2010), pp. 2536–2559. http://press.endocrine.org/doi/abs/10.1210/jc.2009-2354
[3] E.Y. Ko, K. Siddiqi, R.E. Brannigan, E.S. Sabanegh Jr. Empirical medical therapy for idiopathic male infertility: a survey of the American Urological Association. J Urol, 187 (2012), pp. 973–978. http://www.sciencedirect.com/science/article/pii/S0022534711054607
[4] M.K. Samplaski, Y. Loai, K. Wong, K.C. Lo, E.D. Grober, K.A. Jarvi. Testosterone use in the male infertility population: prescribing patterns and effects on semen and hormonal parameters. Fertil Steril, 101 (2014), pp. 64–69. http://www.sciencedirect.com/science/article/pii/S0015028213030537
