By Amanda Brimhall, N.D., Kirkland, WA
Forever Health Network Practitioner
I LOVE MEN! Yes, you read that right. I love my male patients, and I want to help them feel as healthy and vital as possible. One of the important ways that men can optimize vitality is to replace their hormones to youthful levels. With so much conflicting information circulating about hormone restoration, are you confused about the safety of testosterone replacement therapy? Well, you are not alone.
Sensationalized Studies Provoke Fear Despite Glaring Flaws in Methodology
A few years ago, the FDA required that a Black Box warning label be placed on all testosterone prescriptions, baffling patients yet again about the safety of testosterone replacement. Despite more than 60 years of studies showing a positive benefit from bioidentical (not anabolic, non-bioidentical) testosterone, two studies seemed to be creating confusion. The studies were not randomized, controlled clinical trials, and both have been determined since by a panel of experts to be seriously flawed and limited. This is a classic case of a few bad apples spoiling it for the whole bunch.
Headlines in November of 2013 declared that testosterone caused an increased risk of heart attack in men. While there is some disagreement in the medical scientific community as to the optimal range for testosterone necessary to confer maximum cardio protection against heart disease and incidents of heart attack, it is generally believed to be from 500 ng/dL to as much as 900 ng/dL. In the highly publicized "flawed" study, the mean testosterone level attained was only 332 ng/dL, considered by experts to be so low as to increase the risk of heart attack significantly. These study participants were not individually dosed or monitored to assure they were receiving an optimal dosage, hence the low level of testosterone achieved.
Bioidentical vs. Non-bioidentical: Is Cardiovascular Risk the Same?
Another reason why people get confused about the safety of testosterone replacement is that non-bioidentical and natural testosterone therapy tend to get lumped together. Non-bioidentical testosterone, abused by body builders and associated with side effects such as hypercholesterolemia and increased heart attack risk, is nothing like the natural testosterone our body makes. There is a huge difference between bioidentical testosterone (an exact molecular match to what your body makes) and non-bioidentical testosterone (doesn't exist anywhere in nature). Extensive data clearly shows that bioidentical testosterone does NOT increase the incidence of heart attack and stroke: It is actually heart-protective! Ironically, sub-optimal testosterone levels in men have been linked to increased incidence of heart disease and mortality.1 Another large clinical study first published in 2015 showed that men treated with testosterone had a 24% reduction in heart attacks, a 36% reduction in strokes, and an unbelievable 56% decreased risk of dying from any cause including all cancers!2
Is the Risk of Prostate Cancer a Concern in Hormone Replacement?
Okay, fine, but what about testosterone replacement causing prostate cancer? Nope. Not true either.
A collaborative review of 18 studies looked at blood levels of testosterone and estrogen in healthy men compared to men with prostate cancer. The results showed NO significant association between the risk of prostate cancer and higher hormone levels.3
So where did the idea that testosterone causes prostate cancer come from? The idea was based on ONE single report from 1941! Geesh! Old myths never die. The confusion about testosterone and prostate cancer is explained by the "Saturation Model" that you can read about in the book "Testosterone for Life" by Abraham Morgentaler, M.D., or in this Life Extension article.
A Harvard Medical School professor, Dr. Morgentaler did a comprehensive review of the research on testosterone and cancer going all the way back to the 1940's. His conclusion: "There is not now, nor has there ever been, a scientific basis for the belief that testosterone causes prostate cancer to grow." Researchers are currently giving estrogen and testosterone therapy to active prostate cancer patients since it improves their overall quality of life and survival rate.
And What About Estrogen?
What about high estrogen as a cause of prostate cancer in men? Strike three, or maybe a foul ball! In several studies, the risk of prostate cancer was 30% lower with a doubling of the concentration of estrogen.4 It turns out the estrogen may result in apoptosis (programmed cell death) of prostate cancer cells. But, fairly, considerable debate remains about the role of estrogen in men's health. The bottom line is that prostate cancer is most common when testosterone levels are low, and lower levels of testosterone are also associated with increased severity of cancer.
Is Prostate Enlargement or BPH (Benign Prostatic Hypertrophy) a Concern?
What about BPH (benign prostatic hypertrophy) and testosterone therapy? Nope, wrong again! A New England Journal of Medicine meta-analysis (a review of many studies) in 2004 determined that there is no evidence that testosterone causes or worsens an enlarged prostate. In fact, it can be beneficial for BPH and symptoms of urinary dysfunction.
Do Any Risks Outweigh the Benefits of Hormone Replacement?
Are there any side effects from testosterone therapy? As my mentor, Dr. Gino Tutera of SottoPelle®, taught me, "If prescribed appropriately, no. Men either feel good, great or awesome!" Of course, there are pros and cons with each type of therapy but I will review them in detail with you during your appointment. For example, one factor to consider when using a topical cream is the potential for transference (contamination) to others such as your kids or wife, so some men may prefer injections or pellets. Decreased sperm count usually results from all forms of testosterone, which could be a concern in younger men wanting to reproduce. However, the majority of men seeking hormone replacement are beyond the age when the desire for more children is a concern. There are alternative treatments available for those who still wish to expand their families.
Despite old myths, bioidentical testosterone does not cause hair loss, hair growth, acne, aggression, gynecomastia (man boobs), cancer, BPH, sleep apnea, heart attacks or stroke. These side effects are only associated with high-dose synthetic, anabolic testosterone abuse.
"Normal" Testosterone Levels May Not be Optimal Levels
Optimizing testosterone back to youthful levels has many proven benefits. What is the optimal level? I aim to get your hormone levels into the upper one-third of a normal reference range, NOT just in the normal reference range since the labs' ranges are too wide! For example, a lab reference range for total testosterone is 250–1000 ng/dl. Your GP may tell you that you are "normal" with a testosterone level of 275. But do you want to feel average or optimal? For a man, the easiest self-test for low testosterone is the absence of morning erections. Since testosterone levels are naturally highest in the morning, it follows that "normal" levels should produce morning erections.
Optimized hormone levels offer countless benefits, including better strength and stamina, more lean muscle mass and less abdominal fat, protection against dementia and Alzheimer's disease, increased bone density, protection against diabetes and insulin resistance, and lowered cholesterol. Other benefits are enhanced mood and well-being, better energy and motivation, improved libido, fewer instances of erectile dysfunction, better skin tone and collagen, protection against heart attack and stroke, lowering of high blood pressure, improvement of arthritis, boost in immune function, strengthened tendons, ligaments, and joints, and improved wound healing.
Testosterone is a controlled substance and requires a prescription from a doctor. As a functional medicine doctor specializing in hormone replacement therapy for the past 15 years, I am well-versed in the complex maze of HRT. I offer a variety of bioidentical hormone prescriptions to meet each patient's unique needs, such as testosterone pellet implants, topical creams or gels, and testosterone injections. The type and dose of hormone are customized for each patient based upon age, lab results, and symptoms.
- Heart. 2010 Nov; 96(22):1821-5.
- Eur Heart J. 2016 Dec 21;37(48):3569-3575.
- J Natl Cancer Inst. 2008 Feb 6;100(3):170–83.
- Br J Cancer. 1999 Jun;80(7):930-4.