This article was first published in The Montreal Gazette.
To begin with, andropause does not, strictly speaking, exist. The idea that men go through something equivalent to menopause is simply untrue. It is true that testosterone levels decrease over time, usually as part of normal aging. For the majority of men, this decrease in testosterone levels requires no treatment. And yet, despite FDA warnings, the rate of testosterone prescriptions has grown rapidly, largely due to some very successful marketing.
In the early 2000s, prescriptions for testosterone for men over 40 were fairly rare. But over the course of the next decade, the number of prescriptions rose sharply and the reason is troubling. A 2017 JAMA paper showed that rising testosterone use was linked to direct-to-consumer advertising.
It may surprise people to know that such advertising is illegal in Canada, and with good reason. Research suggests that it promotes the prescription of brand name drugs and potentially the over-prescription of costly medications. Concerns about direct-to-consumer advertising recently led the American Medical Association to call for a ban on pharma ads to the public. However, it is difficult to stop people from consuming media directly from U.S. sources and it is impossible to police the internet. There are also enough loopholes in the Canadian law that most Canadians regularly see drug ads in some way.
The very successful marketing for testosterone was centred on the “Low T” campaign, which was made up of websites like lowt.ca and isitlowt.com. The websites listed symptoms like lack of energy, decreased libido and grumpiness as possible symptoms of low testosterone and suggested people talk to their doctor, many of whom got the same promotional material. Because the websites never mentioned the name of the product (Androgel) it did not qualify as marketing and was allowable under Canadian law.
The cynics among you will likely point out that these symptoms are common and with the possible exception of grumpiness are to a large extent consequences of normal aging. But it would appear the marketing was so successful that many patients being prescribed testosterone did not actually need it or have any justifiable medical reason for its use.
Data from Ontario found that between 1997 and 2012 testosterone prescriptions rose to the point that roughly 1 in 90 men over the age of 65 were being prescribed testosterone, but only 6 per cent had a conclusive diagnosis of hypogonadism that would justify the prescription. One analysis found that roughly one out of four patients being started on testosterone therapy weren’t even tested for testosterone deficiency before hand.
Enthusiasm for testosterone therapy cooled somewhat when two studies in 2010 and 2013 linked testosterone therapy with cardiovascular disease. The data here is not definitive though, and the 2015 TEAAM study failed to show any such link. The TRAVERSE trial will hopefully settle the issue, although its results are still at least three years away from being published. Still, the FDA was concerned enough about the data to issue a safety communication in 2014 and require a change to product labels.
Unfortunately, despite the safety warnings, rates of testosterone prescription remain high. A recent research letter in JAMA Internal Medicine found that on-label, i.e. approved, use of testosterone remained fairly constant between 2007 and 2016. However, off-label use rose sharply. While it did decrease a little after 2014, it remained well above 2007 levels with annual spending of $402 million, versus $108 million 2007.
In the end, it would seem that many men are still being prescribed testosterone they do not need. Some men, about 2 per cent, do experience symptoms from low testosterone levels later in life though severe testosterone deficiency is only seen in under 1 per cent.
It is tempting to believe that testosterone therapy will give you back the vitality of youth. But before you start taking the treatment, make sure there’s actually something wrong.
Want to comment on this article? View it on our Facebook page!