Hormone Replacement in Older Men

We read a lot about the benefits and risks of hormone replacement in postmenopausal women. How about replacing hormones in older men?

A minority of older men have significantly low testosterone levels

Although men don’t go through the dramatic menopausal changes that often accompany a rapid decline in the production of female sex hormones, blood levels of the male sex hormone, testosterone, also decline with increasing age, albeit more gradually. While the majority of older men maintain adequate blood levels of testosterone, by age 70 about 30 percent of them have low testosterone levels (less than 300 ng/dL), referred to as hypogonadism.

Manifestations of hypogonadism

I recently saw a TV ad that urged men to get their testosterone levels checked for all the wrong reasons: low energy, fatigue, and diminished strength and vigor. These symptoms, which may accompany hypogonadism, are not uncommon among healthy older men. Loss of libido (sexual interest and drive) and sexual dysfunction are more specific manifestations of hypogonadism. Erectile dysfunction accompanies low testosterone levels but can result from a number of other causes such a diminished blood flow due to atherosclerotic narrowing of arteries. Another common result of  hypogonadism is a decline in bone mineral density that can increase the risk of fractures. Loss of muscle mass and strength are additional features of hypogonadism, but they are also common in older men with normal testosterone levels. Men with real symptoms of sexual dysfunction should see their doctor for a test of blood testosterone, the only definitive way to make the diagnosis or hypogonadism. And the diagnosis requires more than a single low value because of inaccuracies in the blood tests for testosterone.

Benefits of hormone replacement for men with hypogonadism

In men with low testosterone, replacement brings modest improvements in libido and erectile problems. In addition, bone mineral density increases, though no studies have shown a lowering of spine or hip fractures. Testosterone replacement also diminishes fat accumulation and increases muscle mass. The reduction in body fat may improve response to insulin and thus lessen the risk of diabetes. Some research trials have shown that the increased muscle mass is associated with enhanced strength, but many others have not found an increase in strength.

Does hormone replacement pose dangers? 

Because testosterone feeds the growth of prostate cancer, there has long been a concern that testosterone replacement might worsen or initiate prostate cancer. There is little evidence that hormone replacement raises the risk of developing prostate cancer. However, men should undergo a rectal examination and blood tests to minimize the likelihood that they already have prostate cancer before staring testosterone replacement. 

A recent report in the New England Journal of Medicine found that testosterone replacement for six months was associated with a significant increase in the incidence of heart attacks and strokes in older men (average age 74 years), many of whom had significant risks for cardiovascular disease, like high blood pressure, obesity, and type 2 diabetes. These findings suggest cautious hormone replacement, perhaps using lower doses of testosterone, in men at higher risk for cardiovascular disease.

Hormone replacement for older men with normal testosterone levels

Many ads on the Internet promote testosterone products as a way for older men to gain strength and slow the aging process. I strongly believe that testosterone use should be restricted to those with measured low testosterone levels.