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New guidelines can help physicians treat men with low testosterone. Getty Images
  • Testosterone prescriptions have tripled in recent years.
  • Now the American College of Physicians has released new guidelines on when to prescribe the hormone.
  • They advise it shouldn’t be used to improve energy or cognition, but it should be used to treat sexual dysfunction.

Testosterone therapy is on the rise, but experts are warning it needs to be used only in approved circumstances.

Today, the American College of Physicians (ACP) released new clinical practice guidelines that advise doctors to prescribe testosterone only to treat sexual dysfunction in men experiencing age-related low testosterone.

The guidelines don’t address screening or diagnosis of low testosterone levels (hypogonadism), or monitoring of those levels.

The American Academy of Family Physicians (AAFP) endorses the new recommendations, which apply to men with age-related low testosterone.

The American Urological Association (AUA) reports that testosterone testing and prescriptions for testosterone replacement therapy (TRT) have nearly tripled in recent years.

Studies also show that up to a third of men who are using testosterone therapy don’t meet the criteria to receive a diagnosis of testosterone deficiency.

“Many of the symptoms of low testosterone are also associated with aging, and many physicians and consumers have pursued TRT to combat these issues. However, there is a lack of evidence to support replacement as a solution to these problems and a lack of evidence to support TRT as an effective tool to combat this,” said Dr. Brian Norouzi, a board certified urologist with St. Joseph Hospital in Orange County, California.

The ACP recommends that healthcare providers discuss the potential benefits, harms, and costs of TRT with men who want to treat sexual dysfunction due to age-related low testosterone.

“In this case, we’re looking at age-related low testosterone, so we know 20 percent of men over 50 have low testosterone, 30 percent of men over age 70, and that 50 percent of men over age 80, so we know that the ability to make testosterone drops off with age,” ACP President Dr. Robert M. McLean, MACP, told Healthline.

The ACP also advises physicians to reevaluate a patient’s symptoms within the year and regularly thereafter. They should also discontinue testosterone treatment if sexual function doesn’t improve.

“The urological association and the [Endocrine] Society have both recommended that before any TRT is started, patients should be informed that the evidence is inconclusive whether testosterone therapy improves cognitive function, measures of diabetes, energy, fatigue, lipid profiles, and quality of life measures.

“The ACP recent guidelines appear to reflect this, and as many recent guidelines have done, firmly state — since there are no consistent studies showing its benefits — the evaluation and usage should be limited to reduce the expense of screening and treatment costs,” Norouzi said.

Most importantly, the ACP advises that doctors shouldn’t prescribe TRT to improve a patient’s energy, vitality, physical function, or cognition. Evidence indicates testosterone treatment isn’t effective for these symptoms.

“There was some slight benefit in improving sexual function, if they were having some sexual dysfunction like low libido or erectile dysfunction. So if they had that, taking extra testosterone did seem to have a good chance of having some benefit. However, if men had issues of vitality, energy, cognition/memory changes, those subjective symptoms did not seem to improve with extra testosterone,” McLean said.

Norouzi adds that until more studies can be done showing the long-term benefits are worth the cost and risks, it’s best to avoid using TRT for vague symptoms.

He added that many of these symptoms “are generally caused by other factors, such as age, lack of sleep, stress, and poor physical conditioning from lack of exercise.”

The ACP says the yearly cost of TRT in 2016 was just more than $2,000 per patient for the transdermal patch, compared with less than $160 for the intramuscular injection, according to information recorded in the 2016 Medicare Part D Drug Claims data.

Because the injection is much less expensive and clinical benefits are similar, the ACP recommends that when TRT is prescribed, healthcare providers should consider relying primarily on injectable testosterone.

“Most men are able to inject the intramuscular formulation at home and do not require a separate clinic or office visit for administration,” McLean said in a statement.

“Side effects of TRT replacement may include a possible increased risk of heart attack and stroke, gynecomastia (which is breast enlargement), a potentially lethal blood clot in the veins, and increased blood counts called polycythemia,” Norouzi said.

“There is also potential for dependency, because when the drug is discontinued, patients’ T levels are often lower,” he added.

Norouzi also says infertility, reduction in size of testes, and enlargement of the prostate are other risk factors that must be considered.

McLean points out that the studies the ACP looked at showed no clear, long-term adverse effect in men using TRT for age-related low testosterone.

However, he emphasized, “If people aren’t getting benefit, largely sexual benefit from it, then the advice would be to please consider stopping it, because there’s no other benefit that you’re getting. This is not the fountain of youth. This is not overall improving energy level, vitality, cognition, that kind of thing.”

The American College of Physicians (ACP) released new guidelines regarding testosterone replacement therapy (TRT). The advice is that TRT should only be prescribed to treat sexual dysfunction in men with age-related decline in hormone levels.

The ACP says there’s insufficient evidence that TRT improves anything more than sexual function.

Experts emphasize that until more research is done showing long-term benefits, it’s best to avoid using TRT for symptoms like energy, vitality, physical function, or cognition.