A lot has been going on the past few months, so I have been silent on the blog-post front (aside from two very frustrating fake posts due to hackers!). In the meantime, I have gotten married, and I’m excited to get back in the swing of work after a fantastic week away with my new bride! Luckily, while on my honeymoon, my patients kept track of the news for me– and one of them was kind enough to alert me to this article that appeared in the Wall Street Journal. The authors looked at 6400 men who received testosterone injections. All of the men were past age 65– which is the group we want to look at, as recent news articles have focused on risks of testosterone therapy in older men with heart disease. (I discussed those news pieces at length previously, in this post and also in this one.)
This study only looked at men who received testosterone injections– unlike the previous two studies I posted about, which lumped all types of testosterone prescriptions (gel or patch vs injection) together. Interestingly, 26% of the men who got testosterone had a history of heart disease. Contrary to the recent “anti-testosterone” press, many previous studies have shown that men who receive testosterone have a LOWER risk of heart attacks and death: A review of those studies appeared in the Journal of the American Medical Association (JAMA) six months ago and can be found here. (Another review from 2012 can be found at this link.) Consistent with the bulk of previous papers on testosterone replacement in men, the men in this study who had heart disease did very well: giving testosterone to the men at highest risk for having a heart attack actually LOWERED their risk by 30%, compared to the men who didn’t get testosterone.
The search for unexplored territory
This study is not the “study to end all studies” on testosterone therapy. Just like the previous two studies I discussed, this one involved no patient follow-up: they simply searched Medicare databases for men who were prescribed testosterone injections, and then searched diagnosis codes to see how many of them had heart attacks in the ensuing years. Some of these men got only a couple of injections, which no doubt were at least a month apart, providing very inconsistent levels. The injections were in many cases 100mg or even 200mg, which yields grossly supraphysiologic levels (followed by a “crash”), rather than mimicking natural production more closely. As has been discussed previously, I believe that, like all preventive medicine, testosterone is most helpful in the context of a lengthy discussion about proper diet and exercise, and is best used in frequent smaller doses, providing relatively steady physiologic levels. The founding physicians in my current practice, Evolved Science, and my previous practice, all started practicing hormone replacement therapy around 1997, and all provide care to both men and women. Roughly 1500 men have received testosterone therapy in our New York offices thus far. We have tracked these men closely, and their health outcomes are excellent. However, many of our patients are quite pro-active about their health, and our follow-up is relatively rigorous. Even if we join forces with other like-minded practices to increase our statistical power, there is no way to compare our outcomes to studies like this one, where patients are given “a bunch of shots” and then some years later the authors check what happened to them. In other words, though the outcome of this study is roughly in line with what I would expect (decreased risk of heart attack in older men on testosterone), I don’t think this added anything of significance to the literature already out there. If we expect to enrich the conversation, we may want to get some preventive medicine practices together and show as a group what we can do for our patients when they receive the guidance and follow-up they deserve.