The American Urological Association (AUA) has followed closely the recent media attention regarding reports that testosterone therapy increases cardiovascular events in men as well as the FDA's stated intent to review cardiovascular risk with this treatment in men with hypogonadism. The AUA notes there is also contradictory evidence suggesting a beneficial influence of testosterone therapy on cardiovascular risk. Definitive studies have not been performed.
The AUA is also concerned about the potential for misuse of testosterone for non-medical indications, such as body building or performance enhancement.
Hypogonadism is defined as biochemically low testosterone levels in the setting of a cluster of symptoms which may include reduced sexual desire (libido) and activity, decreased spontaneous erections, decreased energy and depressed mood. Men with hypogonadism may also experience reduced muscle mass and strength and increased body fat. Hypogonadism may also contribute to reduced bone mineral density and anemia. Testosterone therapy is an appropriate treatment for hypogonadism after full discussion of potential adverse effects. Treatment requires follow-up and medical monitoring. Testosterone therapy in the absence of hypogonadism is not appropriate.
Increased awareness about hypogonadism has been stimulated by an increase in availability and diversity of patient-acceptable forms of testosterone replacement options in recent years. The management of hypogonadism should start with careful evaluation by a physician experienced in diagnosing hypogonadism. Many of the symptoms are non-specific and may be multifactorial in origin. Hence, symptoms may not be necessarily linked to hypogonadism alone. This fact needs to be considered in the overall evaluation.
The diagnosis and management of testosterone deficiency should be made by a physician with training in the condition and its treatments. The diagnosis should be made only after taking detailed medical history, physical examination, and obtaining appropriate blood tests. Testosterone therapy should not be offered to men with normal testosterone levels. Testosterone therapy is never a treatment for infertility.
The potential adverse effects of testosterone therapy should be discussed prior to treatment. These include acne, breast swelling or tenderness, increased red blood cell count, swelling of the feet or ankles, reduced testicular size and infertility. Current evidence does not provide any definitive answers regarding the risks of testosterone therapy on prostate cancer and cardiovascular disease, and patients should be so informed.
The optimal follow-up of men on testosterone therapy has not been defined, but should include measurement of testosterone level, PSA and hematocrit. Other patient-specific measures may be appropriate.
The AUA recognizes and encourages the need for increased educational awareness of the benefits and risks of testosterone therapy among both patients and health care providers.
Board of Directors, February 2014