Low T and Heart Disease

As most men are aware, testosterone is an important hormone for a number of functions in the body – optimal levels help men feel vital, gain muscle mass, think straight, act with high self confidence and assertiveness, maintain balanced mental health, and perform athletically and sexually. The commercials for “low T” will attest – diminished testosterone levels can mean frailty, muscle loss, impaired cognition, fatigue, depression, and increased risk of type II diabetes. Higher testosterone has also been definitively linked to a lower risk of cardiovascular events like strokes and heart attacks.

However, due to a media miscommunication in 2013, I still have patients who are concerned about the dangers of testosterone replacement. I’d like to dispel the myth.

The age-related decline of men’s testosterone levels is inevitable, just as is the decrease of estrogen and progesterone levels in women around perimenopause. Unfortunately, we don’t tend to screen men for low testosterone levels because there’s no strong indicator of decline aside from the above non-descript symptoms (for women it’s easier – they start to have irregular menstrual cycles and then stop having them all together). But unless men replace their diminishing testosterone, they’re at risk for health problems including strokes and heart attacks.

There has been lots of hype in the media in the past few years debating the link between testosterone and heart disease risk. When headlines surfaced on November 5, 2013 from a study that linked men using testosterone therapy with greater heart attack risk, the media went crazy. Reports suggested that taking exogenous testosterone were dangerous, increasing the risk of cardiovascular events and even death. Unfortunately (as with most things) the headline doesn’t tell the full story, and it requires a critical eye to evaluate the true relationship.

The study from November 2013 had some pretty significant flaws that were later rebutted by other scientists and health professionals – first being that the men were not individually dosed or monitored, and they failed to restore their testosterone to heart-protective levels. They also failed to measure estrogen levels in the study, an independent risk factor for heart disease in men – and didn’t account for aromatization of the extra testosterone into estrogen by adipose tissue (ie. If the men included in the study were overweight).

Other high quality studies done to investigate the link between testosterone and heart disease have shown, fairly definitively, that the relationship is exactly the opposite (1,2,3):

Testosterone, and testosterone replacement therapy, when administered and monitored appropriately, is protective against cardiovascular disease.

Testosterone therapy, in men who require it, improves insulin sensitivity and lipid profiles. It may also possess anti-inflammatory and anti-coagulant effects.   Here’s a list of benefits generated from a 2013 study of men who have low T, treated with replacement therapy:

-reduced LDL (“bad cholesterol”)

-reduced triglycerides

-reduced fasting glucose

-reduced C-reactive protein (inflammatory marker associated with cardiovascular disease)

-reduced liver enzymes

-reduced blood pressure

-reduced hemoglobin A1C (marker of long term blood sugar control)

-increased HDL (“good cholesterol”)

The important thing to remember is that we’re always aiming for balance – with everything, there’s a sweet spot. One study identified that the threshold level for benefit with testosterone replacement therapy is >500ng/dL. Contrast this with the original study, that blindly gave testosterone to male subjects and only raised their levels to an average of 332.2ng/dL. Raising testosterone too high isn’t beneficial either – in men who wish to have children, testosterone replacement should never be given (it reduces the signal from the brain to the testes asking for sperm replacement and can cause irreversible azoospermia), high testosterone can increase red blood cell counts, decrease HDL, increase blood pressure, and increase cardiovascular risk. It is crucial to monitor levels.

In the case of a man trying to conceive or planning to have children in the future, any doctor would never recommend testosterone replacement. However, there are some safe and natural ways to increase natural testosterone production in these men – herbs like Maca and Tribulus, and minerals like zinc and selenium can help elevate testosterone levels naturally, and increase libido, muscle mass, energy, self-confidence and sexual performance in men of child-bearing age.

The idea to remember is this – testosterone levels naturally fall as men age. When low testosterone begins to cause symptoms, it may be indicated to check levels and take a prescription of appropriate, individualized doses of testosterone therapy from your medical doctor. Make sure your doctor checks estradiol and DHT levels, so you know your testosterone isn’t being converted to estrogen (causing breast tissue changes, mood swings, and weight gain/fluid retention) or DHT (which causes prostate growth, acne and male pattern baldness). And monitor your testosterone frequently to keep levels around the protective value of 500ng/dL.

Testosterone replacement therapy is safe when administered in the above way – a 2010 review found there to be no increased risk of the development of prostate cancer, prostate related urinary symptoms or elevated PSA with appropriate testosterone replacement. The goal is to aim for proper physiological levels – nothing too high or too low that the body doesn’t know how to respond to.

For men who suspect they have low testosterone levels, we investigate signs and symptoms, try natural herbal support, and test to see how things are improving in the long term. We’ll suggest testosterone replacement in older men who aren’t planning on having any more children, when it’s indicated by lab values. If you suspect you may have low testosterone, bring it up to your doc at your next appointment – it could save your heart.

In health,

K.

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