Cardiovascular Disease and Testosterone Replacement Therapy (TRT) Part I

January 7, 2021

In 2002, research outcomes from the Women’s Health Initiative changed medicine’s opinion of exogenous estrogen being beneficial for women, to being harmful for women.  Similarly, in 2013, research outcomes from the Veterans Study changed medicine’s opinion of exogenous testosterone being beneficial for men, to being harmful for men.  What happened?!  Where is the science?  What or who do you believe?

I preface this review of ‘Cardiovascular Disease and TRT’ with my beliefs or biases.

  1. I believe the body needs to be in balance to be metabolically efficient.
  2. I believe good diet and exercise are the cornerstones of health at any age.
  3. I believe signs and symptoms are our body’s communication system telling us something is wrong, and therefore we need to change something.
  4. Your normal testosterone level is the number at which you have no complaints attributable to low Testosterone or high Testosterone.
  5. Personally, I can’t remember any patient with a testosterone level of less than 50% on the normal reference range who did not have symptoms of low testosterone.
  6. I don’t believe you have to be on Testosterone the rest of your life in all cases of hypogonadism.
  7. Finding good, prospective studies looking at testosterone replacement in men is very difficult.

Background History of Testosterone Replacement Therapy (TRT)

Although Testosterone was first synthesized in 1935 and proved to have substantial benefits in men whose testosterone levels were deficient, the use of TRT has not been used extensively until the last 15-20 years.  A testosterone deficiency in men is called “hypogonadism”.

The delivery of testosterone pellets placed under the skin in the buttocks was first done in 1939 for men, as were estrogen pellets placed in the same fashion for women.  Doctors are still using this procedure today.  Hence the use of Testosterone and Estrogen Replacement is almost 100 years old!  And yet, TRT has become most popular in the last 15 years.  What happened?

In 1940 an article in the New England Journal of Medicine (NEJM) noted improvements in sexual desire and performance, increased strength and sense of well-being when men with hypogonadism were treated with testosterone.*   Hence, testosterone was called the “honeymoon” hormone.  Men today see these same results with TRT.

For 30 years testosterone maintained “an acceptable safety profile and literature suggesting a decreased cardiovascular risk with low levels of  TRT” as well as decreased Type II Diabetes and overall increase in general health and well-being.

Prostate Cancer and TRT

In the 1940s, a man with metastatic prostate cancer was castrated to lower his testosterone levels.  After this, his metastatic prostate cancer got better.  Note this was a one patient “study” from which our treatment of prostate cancer is now based.  The concept and fear testosterone causes prostate cancer was then born, hence doctors shied away from using testosterone leaving hypogonadal men without options for improved good health.

When I first started using testosterone in men, cancer was the biggest concern and the idea of even doing TRT was edgy at best. This major concern is now laid partially to rest because of research done by Abraham Morgantaler, MD, a Harvard Urology professor who has literally spent his whole adult life studying testosterone.  Morgantaler’s clinical research showed an increase incidence in prostate cancer if testosterone levels were 400 ng/ml or lower.

Cardiovascular Disease Emerges in TRT

The current belief dissuading TRT being prescribed among traditional doctors today is the concept cardiovascular disease is increased when TRT is used.  This belief arose from an article published in the well renown ‘Journal of the American Medical Association (JAMA)’ in November 2013. ***   Just as the women’s Health Initiative results were grabbed and sensationalized by the media proclaiming estrogen was harmful to women, the media grabbed and sensationalized the results of the VA’s research proclaiming there was ‘increase of cardiovascular disease, stroke, and death using TRT.’  In both cases, it led to doctors immediately stopping estrogen therapy in women, and testosterone therapy in men.  The effects of doing this may have led to increased health risks in those patients who were being helped by hormone therapy.

When the VA results were published Abraham Morgantaler, MD, who knew the many benefits of TRT in men, found the author’s statistical data was added incorrectly.  He immediately called the editor of JAMA magazine and asked for a withdrawal of the article as he proved the mistake over the phone to the editor.   When the statistics were added correctly, the results proved the opposite of what the title stated.  ‘Mortality, myocardial infarction, and stroke’ was actually lower in men using testosterone versus those that did not use testosterone. ****  Most doctors were not aware of this mistake as JAMA refused to pull the article and instead noted the mistake in the editor’s column but did not state it completely changed the outcome.  This one article heralded the controversy  of cardiovascular disease and TRT.  In 2015, Morgantaler et al wrote a review article, “Testosterone and cardiovascular disease-the controversy and the facts”.***   I encourage you to read it.

When a doctor states it is well known testosterone causes cardiovascular disease, I ask for the journal article proving it.  I have never received any articles from any of those doctors.  I ask you to do the same.  It is important to understand the facts. If something is confusing to you, it is usually because you don’t have all the facts.  Ask your doctor for the journal articles supporting their beliefs.  This is how we all learn……… More to come…

Have an awesome day.   Dr D

Posted in Cardiovascular Assessment, Cardiovascular Disease