Respectful Insolence

A man on TV is selling me a miracle cure that will keep me young forever. It’s called Androgel…for treating something called Low T, a pharmaceutical company–recognized condition affecting millions of men with low testosterone, previously known as getting older.

The Colbert Report, December 2012

And now for something completely different…sort of.

Thanksgiving is tomorrow, and I’m busy. Fortunately, I have material to use that has never been posted on this blog before. For those of you who don’t also read my not-so-super-secret other blog, it’s new to you. For those who do, think of it as an opportunity to see what a different audience thinks of this post. Last weekend, I saw an article from last weekend in the New York Times that dropped a topic right in my lap, so to speak, both figuratively and literally. It comes in the form of a long article on something that directly concerns men of a certain age, which unfortunately happens to mean men of my age and older. I’m referring to what pharmaceutical company advertising campaigns have dubbed “low T,” short for low testosterone. It’s not clear how the term “low T” originated but Dr. Abraham Morgentaler, founder of Men’s Health Boston, claims to have coined the term when his patients were embarrassed by their difficulty pronouncing the word “testosterone.” Other sources report that it was Solvay Pharmaceuticals that coined the phrase. It doesn’t really matter where the term “low T” came from. The term has stuck, even though the more “correct” medical term would be hypogonadism, as in a man’s testes not working.

The NYT article appears, very appropriately, not in the Health section of the paper, but rather in the Business section. Indeed, if you believe the hucksters and manufacturers of testosterone replacement therapy, pretty much every man over the age of 40 or 50 is prone to a devastating lack of testosterone that must be replaced, preferably by products provided by big pharma like AndroGel. Indeed, the NYT article, written by Natasha Singer, is entitled ‘Selling That New-Man Feeling,’ and she makes a very good case that selling is what it’s really all about, more so than science-based medicine. Since we haven’t addressed the issue of “low T” in over three years, this NYT article seemed to me like the perfect excuse to revisit the topic, looking at how pharmaceutical companies and doctors sell the concept and whether or not there has been any new evidence to guide us in the last three years.

Apparently, 70 year old men should be as virile as 20 year olds

Three years ago, my two fellow medical bloggers Peter Lipson and Harriet Hall wrote about the phenomenon that’s been sweeping the men’s health world over the last five years or so of diagnosing and treating “low T.” Peter acknowledged that “low T” can be a real phenomenon but pointed out that it generally only affects small numbers of men. Harriet quite rightly pointed out that testosterone, contrary to the way it’s being marketed, is not an anti-aging panacea, contrasting it to how pharmaceutical companies are promoting it. None of this is to say that legitimate diagnoses of low testosterone shouldn’t be treated, but questions proliferate. How low is really “too low”? What are the goals of treatment? Do low or low-normal testosterone levels actually cause the symptoms being attributed to them? For instance, if you wander over to the AndroGel site and look at the sorts of symptoms being attributed to “low T,” you’ll find:

Signs and symptoms of Low Testosterone may include:

  • Fatigue or decreased energy
  • Reduced sex drive (libido)
  • Sexual dysfunction (weak erections, fewer erections)
  • Depressed mood
  • Increased body fat
  • Reduced muscle mass and strength
  • Decreased bone strength
  • Loss of body hair (less frequent shaving)
  • Hot flashes, sweats

There’s then a test, which takes the form of a series of questions:

  1. Do you have a decrease in libido (sex drive)?
  2. Do you have a lack of energy?
  3. Do you have a decrease in strength and/or endurance?
  4. Have you lost height?
  5. Have you noticed a decrease in your enjoyment of life?
  6. Are you sad and/or grumpy?
  7. Are your erections less strong?
  8. Have you noticed a recent deterioration in your ability to play sports?
  9. Are you falling asleep after dinner?
  10. Has there been a recent deterioration in your work performance?

Just for yucks, I took the quiz, and this is what I got back:

LowT

Yes, it turns out that AbbVie, the drug maker behind AndroGel, is very concerned that I might have “low T” and really thinks that I should get myself checked out. I think I’ll probably pass, given the origin of this questionnaire, which is known by the acronym ADAM, which stands for the Androgen Deficiency in Aging Males test:

More than a decade ago, a Dutch pharmaceutical company, Organon BioSciences, asked Dr. Morley to devise a screening questionnaire covering symptoms common to older men with low testosterone. The way Dr. Morley recalls the drugmaker’s instructions, “they said, ‘Don’t make it too long and make it somewhat sexy.’ ”

In return, he says, Organon gave $40,000 to his university for research into the effects of testosterone on muscle. Along the way, Dr. Morley’s quiz acquired an official name that emphasized its intended audience was older men: the Androgen Deficiency in Aging Males, or ADAM, test.

That test has become standard fare on brand-name drug sites like androgel.com and on informational sites like AbbVie’s IsItLowT.com — where the ADAM test has been re-branded as the “ ‘Is It Low T?’ Quiz.” If the questions drive many men to identify themselves as low-T sufferers and visit their doctors seeking remedies, well, that is their purpose.

Indeed, it is, which is why I failed it. Particularly amusing is the section where it asks if you’re falling asleep after dinner. A particularly pithy quote was included from Dr. Adriane J. Fugh-Berman, an associate professor at Georgetown University Medical Center in Washington and director of Pharmed Out, who quipped, “Depends how long after dinner. We all do eventually. It’s called sleep.” Also, I would add, if it’s a particularly carb-rich dinner, I might indeed doze off not long after. Clearly many of us who will be partaking tomorrow of our yearly Thanksgiving feasts suffer from low T!

It turns out that these “low T” advertisements take advantage of a loophole in the law. The FDA and Federal Trade Commission carefully monitor pharmaceutical company advertising. In particular, the FDA looks out for drug companies that advertise “off-label” uses for their drugs; i.e., uses for which the drug is not FDA-approved. As we’ve discussed from time to time here at SBM, off-label prescribing is a common and often accepted practice that is not necessarily outside the purview of science-based medicine, given that FDA approval can lag behind the evidence for a new indication for a drug. However, pharmaceutical companies are not permitted to promote such uses. After all, if they could market drugs for off-label uses, then why bother going to the trouble of doing all those expensive and pesky clinical trials to gain approval for new indications?

There is one sort of advertising campaign, however, that the FDA doesn’t really regulate. You can look at it as a similar end run around FDA regulations used by supplement manufacturers when they make vague “structure-function” claims. In this case, the end-run is known as “unbranded” promotions or “disease-awareness” campaigns. These are promotions that do not advocate the use of a specific brand of a drug and/or promote “awareness” of a condition:

The Food and Drug Administration closely regulates advertisements for brand-name prescription drugs, but does not generally regulate unbranded campaigns. That two-track system, says John Mack, an analyst who runs a blog called Pharma Marketing, has enabled companies to position low T as a malady with such amorphous symptoms — listlessness, increased body fat and moodiness — that it can be seen to afflict nearly all men, at least once in a while. Drug makers also promote low-T screening quizzes directly to consumers, Mr. Mack says, in an effort to prompt men to seek testosterone prescriptions from their doctors.

For this sort of campaign:

Earlier this year, Medical Marketing & Media, a trade magazine, named two AbbVie executives as “the all-star large pharma marketing team of the year” for promotions of AndroGel and unbranded efforts to advance low T.

“It didn’t hurt that baby boomers have proven less than shy about availing themselves of any product that they believe will increase their quality of life,” an article in the magazine said. The article lauded AbbVie’s DriveForFive.com, an unbranded site that encourages men to have regular checkups and to ask their doctors about five tests, among them tests for cholesterol and blood pressure — and testosterone.

Mr. Freundel of AbbVie described the effort as “a national disease-awareness initiative aimed at encouraging men to take a more proactive approach to their health.” The F.D.A., he added, encourages companies to develop such initiatives “because they serve an important role by enhancing awareness of health conditions.”

Described in Medical Marketing & Media thusly:

AbbVie took a taboo topic and, via a cagey media-and-marketing presence, rendered it less wince-inducing among its target audience. It did so at a time when a number of critics voiced their concerns that the marketing and use of testosterone-boosting products had gotten ahead of the science.

Notice how blatant MMM is in trumpeting this as a triumph of advertising over science. AbbVie overcame all those nasty doctors trying to tell people that there’s no good science to indicate that all these millions of men need testosterone replacement therapy. I guess AbbVie showed them! Indeed, this marketing campaign, coupled with other, similar campaigns by other testosterone manufacturers and physicians specializing in men’s health, testosterone prescribing is way, way up. Indeed, a recent study in the Medical Journal of Australia concluded:

In the absence of any new indications, off-label testosterone prescribing has increased in most countries in 2000–2011, especially over the last half of the period. The increased testosterone prescribing appears to be primarily for older men and driven by clinical guidelines that endorse testosterone prescribing for age-related functional androgen deficiency (andropause). By eliminating the fundamental distinction between pathological and functional androgen deficiency, these guidelines tacitly promote increased testosterone prescribing, bypassing the requirement for high-quality clinical evidence of safety and efficacy and creating dramatic increases in prescription of testosterone products.

In the U.S., monthly use per 1,000 population increased nearly ten-fold between 2000 and 2011; in Canada, the increase in usage was nearly 40-fold, even though it started at about the same rate in 2000. It is truly astounding how much the use of testosterone supplementation has increased in developed countries. It’s almost impossible to escape the advertising. It’s in newspapers, on television, and all over the Internet. As I’ve seen it quipped, ads for “low T” seem to be directly competing with the ads, ubiquitous since the late 1990s, for erectile dysfunction drugs. One wonders when “awareness” of “low T” will surpass awareness that, seemingly, older couples must sit side-by-side in separate bathtubs before getting it on, as anyone who’s seen a Cialis ad knows. (And, yes, I’m with former ScienceBlogger revere when he asks, “What’s up with that?“)

But I digress. Let’s take a look at “low T” and what the scientific evidence, rather than the marketing hype, says about it.

Low T, high T, fitting testosterone to a T

The Is It Low T? website claims that “millions” of men in the US suffer from “low T.” Perusing the various ads and promotional materials, one will soon see an estimate of 13 million men in the US over the age of 45 suffering from “low T.” This estimate is sometimes attributed to the American Diabetes Association, but if you look at the link to a page about low testosterone on the ADA website it says nothing about the prevalence of this condition, other than that it is “common.” As Jim Laidler pointed out in the comments of Harriet’s post on the topic, according to the US Census Bureau, there are over 53 million men over age 45 in the US as of 2010. This would mean that nearly a quarter of men over 45 have “low T.” It’s a figure that seems rather high and difficult to believe.

Part of the problem is that as is the case with estrogen levels in women, testosterone levels in men begin decreasing after the age of 30. The topic was reviewed well in the New England Journal of Medicine nine years ago, so this is not new information. Contrary to the abrupt and rapid decrease in sex hormone levels that occurs in women when they enter menopause, in men testosterone levels decrease more slowly, with the serum total testosterone concentration decreasing from a mean of about 600 ng/dL (20.8 nmol/L) at 30 years of age to a mean of about 400 ng/dL (13.9 nmol/L) at 80 years, although, the review noted, the range is wide at all ages. However, the “normal” range for serum testosterone levels varies with age, decreasing as a man ages. In younger men, the low end of the normal range is generally considered to be around 300 ng/dL, and that is often the level recommended as the cut-off by the “low T” websites.

Testosterone levels also vary considerably in that they can be affected by illness and medications such as opiates and glucocorticoids. They also can vary significantly due to circadian and circannual variations, episodic secretion, and measurement variations. In the circadian variation, peak levels are noted in the morning, although this variation is less in older men. Indeed, even with this blunting of the circadian variation of testosterone levels, a significant proportion of men over 65 with low testosterone levels in an afternoon blood draw will have normal levels in a morning blood draw. Depending on the specific male sex hormone, the various standard deviations imply that a clinician can expect to see a difference exceeding 18% to 28% about half the time when two measurements are made on the same man and a difference exceeding 27% to 54% a quarter of the time. Also, 15% of healthy young men will have a testosterone level below the normal range in any 24 hour period. That is why the Endocrine Society, in its clinical practice guideline for Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes, emphasizes that “day-to-day variations in serum testosterone concentrations were found to be sufficiently large that single testosterone measurements were inadequate to characterize an individual’s levels, and at least two testosterone measurements were needed to diagnose androgen deficiency with greater confidence.”

Funny, then, that a recent study (the same study that found skyrocketing rates of androgen replacement prescribing) also found that among all new androgen users from 2001 to 2011, only 74.72% had had their testosterone level measured in the year prior to starting to take androgen replacement. That means slightly over one quarter of men started on testosterone had never been shown to have low testosterone levels! Given this result, one wonders how careful a workup was done before prescribing testosterone replacement. After all, there are multiple forms of hypogonadism, primary and secondary. Primary hypogonadism is due to failure of the testes to make adequate testosterone, while secondary hypogonadism is due to a problem in the hypothalamus or pituitary gland, the parts of the brain that signal the testes to produce testosterone. The hypothalamus produces gonadotropin releasing hormone, which signals the pituitary gland to make the follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone. Either type of hypogonadism may be caused by an inherited (congenital) trait or something that happens later in life (acquired), such as an injury or an infection, and there are specific workups and tests that need to be done to differentiate between the two, as detailed in the Endocrine Society’s guidelines.

For these men, most likely, testosterone was prescribed for some of those vague symptoms that the “Low T” websites promote as being due to low testosterone levels or to make a man “feel younger.” These are the sorts of symptoms that are relieved by testosterone in testimonials, like this one by former pro football player Daryl “Moose” Johnston, whose complaints were mainly:

I was feeling more tired than usual and I noticed that I was having trouble keeping up with my regular activities. These signs were pretty subtle at first, but it didn’t take long until they started to get in the way of things I loved to do, like exercising. As an athlete and someone who has been active my entire life, I knew something wasn’t right. That’s when I decided to see my doctor.

There’s a term for symptoms like that: Getting old. Yes, it sucks, particularly if you used to be a professional athlete and your identity is heavily invested in being physically fit and active. It often hits athletes hard when they realize that they can’t keep up with young men anymore. But how does one distinguish symptoms that are really due to “low T” from the normal changes that men (and women) experience as they get older? I’m experiencing these sorts of things, even though I was never an athlete and never particularly physically active. I highly doubt it’s due to “low T.” It’s probably because I’m getting older and, frankly, because my lifestyle and diet aren’t the greatest.

All of this brings me to asking whether there is anything to the claims that replenishing low or borderline-low testosterone levels will correct many of the symptoms for which testosterone replacement therapy is prescribed. In considering this question, it is useful to frame it as a series of four questions asked by Peter Lipson three years ago:

  1. Is there a plausible connection between testosterone levels and certain symptoms?
  2. What is a normal testosterone level?
  3. Are there specific symptoms that correlate with lower levels?
  4. Does replacement therapy correct these symptoms?

I’ve already discussed #2 in detail. Question #1 would suggest that, at the very minimum, symptoms of sexual dysfunction, such as decreased libido, infertility, and erectile dysfunction, could be plausible consequences of low testosterone levels. After all, testosterone is the primary male sex hormone. Besides libido, fertility, and sexual function, testosterone also influences energy and stamina, mood, cognitive functioning, bone density, red blood cell production, and maintenance of secondary sexual characteristics.

However, such symptoms can be caused by many things. Depression and medication side effects, for instance, can result in decreased libido. Atherosclerotic vascular disease can result in erectile dysfunction due to decreased blood flow, as can damage to the nerves controlling erection. A number of studies have looked at the symptoms attributed to low testosterone with mixed results, such that it is not unreasonable to characterize the clinical importance of age-related decreases in testosterone as controversial. For example, a recent study of middle-aged and elderly men found that only poor morning erection, low sexual desire and erectile dysfunction were associated with low testosterone levels. Other symptoms, such as decreased vigorous activity, difficulty walking more than one kilometer, fatigue, and loss of energy, all symptoms frequently attributed to “low T,” correlated poorly with testosterone levels. So the answer to #3 really only includes primarily symptoms of decreased libido and erectile dysfunction.

There are other clinical problems that have been attributed to low testosterone, but it is hard to determine whether they are causative or a consequence of the conditions associated with low testosterone. For example, metabolic syndrome has been associated with low testosterone levels. Although testosterone levels were associated with metabolic syndrome, this relationship appeared to be associated with lipid categories, hs-CRP, BMI, and insulin resistance levels and did not appear to be an independent marker for metabolic syndrome. Similarly, a recent review of the literature concluded that low testosterone is associated with depressive disorders but that “there is insufficient evidence to conclude that low testosterone level routinely leads to major depressive disorder in men,” while another recent review concluded that “men with COPD [chronic obstructive pulmonary disease] have clinically relevant lower than normal TT levels” but that “insufficient evidence from short-term studies in predominately male COPD patients suggests that testosterone therapy improves exercise capacity outcomes, namely peak muscle strength and peak workload.”

One of the strongest claims made by advocates of treating “low T” is that low testosterone levels are associated with cardiovascular diseases, such as atherosclerosis, hypertension, and myocardial infarction. A “hot off the presses” review from Belgian researchers based on the literature from 1970 to 2013 concluded:

On the one hand, a modest association is suggested between low endogenous T and incident cardiovascular disease or cardiovascular mortality, implying unrecognized beneficial T effects, residual confounding, or a relationship with health status. On the other hand, treatments with T to restore “normal concentrations” have so far not been proven to be beneficial with respect to cardiovascular disease; neither have they definitely shown specific adverse cardiovascular effects. The cardiovascular risk-benefit profile of T therapy remains largely evasive in view of a lack of well-designed and adequately powered randomized clinical trials.

Also hot off the press, however, is a cohort study published JAMA from the University of Texas Southwestern involving 8,709 men with low testosterone undergoing coronary angiography in the VA medical system, of whom 1,223 started testosterone therapy after a median of 531 days post-angiography. The investigators found that testosterone replacement therapy was associated increased risk of mortality, MI, or ischemic stroke. The effect sizes weren’t huge, but the results were consistent with an earlier small randomized, placebo-controlled trial of testosterone replacement therapy in men 65 or older with limitations of mobility had to be stopped because of a higher number of adverse events in the testosterone group.

There’s no doubt that for men with true hypogonadism, testosterone replacement therapy can have definite therapeutic effects, as both Peter Lipson and Harriet Hall have described, but that’s not what we’re talking about here. Moreover, testosterone replacement has known adverse effects, including sleep apnea, elevated red blood cell count, heart disease, acne, benign prostatic hypertrophy, breast enlargement, reduced sperm production, and shrinkage of testicles. It might also have unknown adverse effects over the long term, as some of the studies cited above show. At the very least, it is not the panacea that it’s advertised as.

Low T: When science meets marketing, marketing wins

The best summary of the controversy over “low T” that I’ve seen appeared in JAMA in August. It was written by Lisa M. Schwartz and Steven Woloshin and entitled Low “T” as in “Template” How to Sell Disease. Schwartz describes that template in terms of three strategies:

  • Lower the bar. By this, Schwartz means to broaden the criteria for a “disease” beyond what was previously accepted, evidence or no evidence. In other words, “lower the bar” for diagnosing that disease, so that more people need “treatment.”
  • Raise the stakes. This involves increasing the claims for the harm that comes from not treating the new condition and the benefits of treating the condition. Schwartz writes: “It is one thing to tell men that Low T can make them grumpy; it is another to say that it can kill them. Messages raising the stakes about Low T have appeared regularly in scientific meeting reports and journal articles7 and often make their way into the news (“Low testosterone could kill you,” according to ABC News).”
  • Spin the evidence. This one is self-explanatory. As Schwartz puts it: “Testosterone therapy results in only small improvements in lean body mass and body fat, libido, and sexual satisfaction, and has inconsistent (or no) effect on weight, depression, and lower extremity strength. Whether these effects are big enough to matter to patients is unknown. Nor is it known whether they are big enough to outweigh the harms of testosterone therapy, i.e., polycythemia that may increase thromboembolic events, edema, serious hepatotoxic effects, gynecomastia, worsening of sleep apnea, prostate enlargement, and rise in prostate-specific antigen level (and potential increased risk of prostate cancer).”

All of these things are going on with respect to testosterone replacement therapy. There is a paucity of evidence that “low T” is the problem that it is advertised to be and even less evidence that testosterone replacement therapy corrects the problems attributed to “low T.” Before pharmaceutical companies launch big money campaigns to make millions of men “aware” of low T, they should be required to do what they have to do before introducing a new drug for a new indication: the appropriate large-scale randomized trials to demonstrate that testosterone therapy for otherwise-healthy aging men whose testosterone levels are below the normal range for young men does more good than harm. Right now, we don’t have that evidence, and we’re not likely to get it from pharmaceutical companies. Right now, except for the small proportion of men diagnosed with “Low T” who really do have symptomatic hypogonadism, “Low T” is a way to extract more cash from more older men. It’s been very effective, too.

Comments

  1. #1 Khani
    November 27, 2013

    Are they going to treat “high T” too? Because I doubt it.

  2. #2 Mephistopheles O'Brien
    November 27, 2013

    Khani – the phrase “high T” would seem contradictory. Unless you actually meant “high tea”, which brings up pictures of scones, cucumber sandwiches, and clotted cream.

  3. #3 justawriter
    November 27, 2013

    I think the medical term for this procedure is a “cashectomy” also know as a “wallet extraction and evacuation.”

  4. #4 Chris Hickie
    November 27, 2013

    I was told as I get older I will have experience the discomfort of low T, but that going from boxers to briefs would take care of that.

    Who’da thought that every little thing not right in my life was really due to something that people on radio ads can fix if I just buy their stuff?

    Now if you’ll excuse me, my wife asked me to go to the hardware store to buy some striped paint.

  5. #5 Eric Lund
    November 27, 2013

    Are they going to treat “high T” too?

    If there were any money to be made, they would. But American society, at least (I can’t speak for the rest of the world) tends to fetishize Manly Men who do Manly Things, so rather than treat this condition, we encourage behaviors and actions which could be loosely described as testosterone poisoning. As a resident of a university town, I see a fair amount of this. Emergency room physicians are paid to deal with the aftermath of testosterone poisoning, but it’s probably one of the less pleasant aspects of that job.

  6. #6 AnObservingParty
    November 27, 2013

    Well, gee, I took the test and I fulfill 7 of the criteria that I’m qualified to (there’s one, as a 19-year-old lady, I can’t answer). Do ladies get a homologous disorder to talk to our doctors about? Here I thought it was just stress piling up…but now I’m concerned. :P

    Hypogonadism is a very real thing…this is trivialization in my mind.

  7. #7 AnObservingParty
    November 27, 2013

    *29 year old lady. See? My performance is suffering.

  8. #8 Eric Lund
    November 27, 2013

    AOP@6: IANAD, but it looks to me like at least five of those questions (including one of the Big Two that supposedly is an indicator by itself of “low T”, the other one presumably being the question you couldn’t answer) refer to symptoms of depression. Which may be correlated with low T in males, but it’s not clear which direction the causality would go (it might go one way in some cases and the other way in other cases). So I would regard that test’s value as low, if not less than zero; depression can be a serious condition.

    As Orac explains in the OP, the female version of “low T” is menopause. But menopause, at least, can be accurately diagnosed (if that’s the right word for a condition that happens to any female who lives long enough).

  9. #9 AnObjectingParty
    November 27, 2013

    @ Eric

    That was exactly my point. Pretty much all of it. Apologies if I was not sarcastic enough to highlight that, it’s tough while typing. That sort of “test” is trivializes legitimate conditions that can be dangerous.

  10. #10 AnObservingParty
    November 27, 2013

    Goddammit, a name typo again.

  11. #11 Shay
    November 27, 2013

    “Low T” is a way to extract more cash from more older men.

    Makes perfect sense. Older men tend to have more cash than younger ones.

  12. #12 lsm
    November 27, 2013

    For some reason, whenever I see the Low T commercial I think of the Sunny D commercial, which suggests that if you use the initial “d” instead of the word “delight” you will be cool and popular. Low T, Sunny D, what’s the dif? Men with low T are also cool and popular because they use the slang “T”, and also because everyone has it. But most of all, because if they use AndroGel their life will be one big Sunny Delight.

    That’s how confused my brain is. I must have Low T.

  13. #13 hematophage
    November 27, 2013

    Several of my buddies are undergoing testosterone therapy as part of FTM therapy. They had to have extensive workups prior to beginning (one friend had to delay his start because of slightly-high cholesterol)…I assume the dosage levels between gender transitions and low T treatments are quite different, but one still wonders why similar considerations wouldn’t need to be made. Less risk of serious side effects in a man who has developed in the presence of testosterone his entire life?

  14. #14 Denice Walter
    November 27, 2013

    Wait until the bio-identical hormone woo-meisters create their own version of this…

  15. #15 Jeff1971
    November 27, 2013

    Quite right. It’s like eyeglasses. For god’s sake, losing your vision is a normal part of aging, and all bidness wants to do is sell you products.

  16. #16 herr doktor bimler
    November 27, 2013

    Signs and symptoms of Low Testosterone may include:

    Wait, what, when did being female become a medical issue?

  17. #17 Eric Lund
    November 27, 2013

    Wait, what, when did being female become a medical issue?

    When certain buttinskis decided that letting females have appropriate medical care in all circumstances offended their religious beliefs and decided to impose those beliefs on all females, not just the ones that share those beliefs.

    But I digress.

  18. #18 herr doktor bimler
    November 27, 2013

    letting females have appropriate medical care in all circumstances offended their religious beliefs

    Well, of course; they suffer from Low-T, so their brains don’t work properly, and they can’t be trusted to make their own decisions.

  19. #19 Krebiozen
    November 27, 2013

    Is it wrong for me to think that a reduction in male libido is in some ways a positive aspect of getting older? I kind of like it.

  20. #20 Denice Walter
    November 27, 2013

    Seriously….
    Because I deal with men who are over 50 on a daily basis…

    A few of these crea… GENTLEMEN complain about the problems they encounter and sound nearly like the questionaire- e.g.
    a tennis instructor feels that he cannot play as he once did and he has lost some hair.
    A business guy/ serious athlete complains about feeling weak and tired
    another business person complains that he feels depressed and has (( shudder)) greying hair.
    “Look at it!” he moans.

    I have found that telling the truth- but looking on the brighter side- may help prevent these poor fellows from wallowing and seeking out pharma assistance for their problems…
    so in the interests of science- my responses:
    1 ” You play better than 99% of players on the planet -btw- have you lost weight?”
    2 ” You are in better shape than most 30 year olds and people are amazed when they hear how old you really are”
    3 “You were depressed when you were 12, be happy you HAVE hair and you are exceedingly handsome. Ageless”.

    As we say in my family: ‘Flattery will get you everywhere’.

  21. #21 herr doktor bimler
    November 27, 2013

    we encourage behaviors and actions which could be loosely described as testosterone poisoning

    I gather that people are actually allowed to *drive* and *handle firearms* and *operate heavy machinery* in that condition.

  22. #22 Gil
    November 27, 2013

    Then again why do women get HRT? Why don’t they accept that getting older is a part of life?

  23. #23 Denice Walter
    November 27, 2013

    @ Gil:

    Some of them have very disturbing symptoms that accompany a lower level of hormones.
    I’m sure that the age factor is not nothing either.

  24. #24 Krebiozen
    November 28, 2013

    HDB,

    I gather that people are actually allowed to *drive* and *handle firearms* and *operate heavy machinery* in that condition.

    When I look at road traffic collision and homicide statistics, and world history, I sometimes cynically wonder if that is entirely wise.

  25. #26 palindrom
    November 28, 2013

    Testosterone-crazed 18-year-olds can be very useful if you’re tasked with, say, pushing the Nazis out of Western Europe.

    Unfortunately, you can be sure that a great many of them will suffer from debilitatiting side effects, some of which make the eventual onset of “low-T” entirely irrelevant.

  26. #27 Mark Thorson
    November 28, 2013

    Isn’t male pattern baldness caused by testosterone? You don’t hear much about that.

  27. #28 Richard Smith
    November 29, 2013

    Interesting piece. I have congenital pan-hypopituitarism, for which I received several years of “real” hGH treatment leading up to my early teens. I’ve just turned 46, and recently had fairly comprehensive endocrinology bloodwork done, and my serum testosterone was just a touch over 100.

    This whole low-T “issue” gets me rolling my eyes almost as much as the “grow young with growth hormone” craze of a while back did. It probably wouldn’t be too charitable of me to wish that more people would fall for these, so that the demand increases and, in theory, drives the cost down for those of us who actually need it. I already have Androgel, although I use it infrequently (something about rubbing cold, runny, alcohol-stinky substances all over my chest, then speed-drying it with a blow dryer, just doesn’t appeal to me as a way to spend part of my day — could the marketers figure out a way to up-sexy that part?), but the $12,000/year (give or take) for hGH treatment is a little out of my budget, even with my drug plan.

  28. #29 Spectator
    November 29, 2013

    “But American society, at least (I can’t speak for the rest of the world) tends to fetishize Manly Men who do Manly Things”

    If you think this is an American phenomenon, try Latin America.

  29. #30 Green Eagle
    Los Angeles
    November 29, 2013

    Listen, they couldn’t get enough males to buy medication for restless leg syndrome, so they got to work on restless penis syndrome. Whatever works, huh?

    My kids know the son of a manufacturer of what the father calls “dick pills.” The kid was driving a Ferrari at the age of 18. Not a bad racket there.

  30. #31 palindrom
    November 30, 2013

    Ironically, the page just loaded with an add at the side showing an attractive woman with bedroom eyes and the headline “I weird trick to boost your testosterone”.

    Perhaps not accidental, since the word “testosterone” appears on the page.

  31. #32 Eric Lund
    November 30, 2013

    palindrom @31: Not at all accidental. Google Ads, and most other such firms, use keywords in their algorithm to decide what ads we see. Which is why you will sometimes see an ad for Suzanne S.’s latest woo-pedaling on this very site, especially if the post mentions Suzanne’s name.

    Of course, they also look at your recent browsing history. So if you have recently been looking for certain medications online, you are disproportionately likely to get ads for such medications.

  32. #33 David N. Brown
    November 30, 2013

    @1: “Are they going to treat “high T” too?”

    One could very well count the Geiers’ Lupron “treatment” for autism, which has been covered extensively here. I would say there are parallels, particularly in that the Geiers claimed that “premature puberty” could be diagnosed by a child’s behavior without testing hormone levels or using any objective physiological criteria. The especially striking irony is that, as I pointed out in my own writings on the subject, is that there is better evidence that children and adults with autism might be prone to LOW testosterone, e.g. frequent reports of low muscle tone.

  33. #34 Arcanyn
    December 1, 2013

    The funny thing is, 50% of the population have a condition which results in 90% less testosterone production, and they live on average 8 years longer.

    It’s strange how so much of the anti-aging quackery out there involves substances which -accelerate- aging (HGH being the most egregious example). It’s like homeopathy, but without the dilution.

  34. #35 Richard Smith
    December 1, 2013

    @Arcayn (#34): Funny story: around 15 years ago, I was taking testosterone pills, which were pretty expensive. I’d just had some tests done, and the doctor called to let me know that I could stop taking the testosterone, as my levels were now well within normal range. Yay! I wouldn’t have to refill the expensive medication! Next day, I get an apologetic call from the doctor saying that he’d misread the chart, checking the wrong age group… and sex.

    (I’m not keen on Andro* in general. The pills are expensive – extra-testosterone-packed so enough survives digestion – while the patch always seemed to prefer to flip over and making my clothes extra-macho, and the gel is just nasty to apply.)

    As for the hGH anti-aging quackery, I’m 46; most people think I’m in my 20s or 30s. I should write a book: “Growing Young *WITHOUT* Growth Hormone.”

  35. #36 Denice Walter
    December 1, 2013

    @ Richard Smith:

    “making my clothes extra macho”

    Are they black leather with studs and spikes?

  36. #37 Chris HIckie
    December 1, 2013

    This topic reminds me of a slightly crude joke:

    This guy gets these chronic migraine headaches. One day he sees a doctor about his problem. The doctor gives him a thorough examination and says, “I can cure your headaches, but I’ll have to remove your testicles to do it.”

    At first the man is horrified at this idea, but the headaches keep getting worse and worse. He can’t work or sleep, his sex life is nonexistent, and he’s generally miserable. Finally, he goes back to the doctor and says, “I don’t care anymore, cut them off. Just get rid of these damned headaches!

    The doctor performs the operation, and immediately the headaches go away. The guy is relatively happy, now. He may not have a sex life, but he figures this is price he has to pay for a life without pain.

    One day, he decides to get himself a new wardrobe. He goes to this nice new men’s shop downtown. As soon as he walks in the door, the clerk looks carefully at him and says, “You wear a 44 long jacket, don’t you?”

    The guy says, “Yeah, how did you know?”

    “It’s in the eye,” says the clerk. “Your neck is seventeen and one quarter inches, but given your build, medium shirt sleeves should work.”
    “That is incredible!” the guy says.

    “Hmm… and you wear a 36 large jockstap.”

    “Ah hah! You’re wrong,” the guy says gleefully. “I wear a 32 small jockstrap.”

    “No, you have to wear a 36 large,” says the clerk.
    “Look, I’m sorry, but you’re wrong. I wear a 32 small.”

    “That’s impossible,” says the confused clerk. “A 32 small jockstrap would pinch your testicles and give you awful migraine headaches.”

  37. #38 alison
    wishing we were still on holiday
    December 1, 2013

    low testosterone, libido, & anti-aging – I am reminded of the late J.R.Brinkley, who made a killing in that area: http://sci.waikato.ac.nz/bioblog/2013/09/goat-glands-greed-and-gullibility.shtml

  38. #39 alittlesense
    December 2, 2013

    First, I have never used any testosterone raising medications, nor do I have any interest in any pharmaceutical company selling such medications. That out of the way, I’m disturbed by some aspects of this and other blog posts by “Orac”. In his never-ending quest for snark, he often falls into condescension when writing about things of which he disapproves. After reading this blog post and many of his other posts, I get the feeling he is a lot like Bill Murray in a memorable scene from “Ghostbusters”. Bill and his paranormal research buddies are questioning a librarian who has seen a ghost, and ask her a number of increasingly inappropriate and stupid questions, ending with “Are you menstruating?” When one of her colleagues asks what that has to do with anything, Murray shoots him a withering glare and announces, “Back off, man. I’m a scientist.”
    Yeah, we all know you are a hot-s**t physician, and we should believe anything you tell us. Just turn the volume down on the snark. You won’t convince anyone of anything buy telling them how dumb and sheep-like they are.

    Having gone through at least one nightmarish, essentially criminal misdiagnosis of a loved one by a pysician who thought he was all that, I tend to obtain second and even third opinions any diagnosis more complicated than a cold. The same person horribly misdiagnosed was seen and treated by another, equally science-based physician and is now fine. So turn down the volume on the “everyone but me and my courtiers is a toothless, brain-damaged yahoo”, OK?

  39. #40 Lawrence
    December 2, 2013

    Wow….that’s Grade A tone-trolling there….

  40. #41 alittlesense
    December 2, 2013

    Oh, and I should mention that all my kids have had all their vaccinations right on schedule.

  41. #42 alittlesense
    December 2, 2013

    Ah, yes. Call out the author on anything and it’s “trolling”. Nice ad hominem.

  42. #43 Lawrence
    December 2, 2013

    Nope – you complaining about his “tone” without addressing anything he actually wrote, is tone-trolling.

  43. #44 Mephistopheles O'Brien
    December 2, 2013

    alittlesense – are you merely complaining about how Orac phrases his posts or do you disagree with him on some of his statements? If you disagree with him, what about? If you’re only concerned about how he states his points rather than the points themselves, how is that not tone trolling?

    I, for one, have no issue with providing feedback that the contempt (or admiration) show in a blog post is misplaced. Saying that someone’s post is too snarky for your taste invites the retort that – in the words of Frank N. Furter – “I didn’t build him for YOU!”

  44. #45 Orac
    December 2, 2013

    Nope – you complaining about his “tone” without addressing anything he actually wrote, is tone-trolling.

    Indeed it is. By definition.

    If alittlesense expects me to change just because he is offended by my “tone,” he is going to be disappointed. I really don’t care if he reads me or not. If my tone bothers him that much, may I suggest other medical blogs that cover similar topics? For example, Science-Based Medicine is excellent:

    http://www.sciencebasedmedicine.org (don’t spoil the surprise)

    I also can’t resist pointing out that, if anything, I have toned it down over the years. I’d love to see alittlesense’s reaction were he to plow back into the archives to around 2005-2007. If you think he’s clutching his pearls now… :-)

  45. #46 Orac
    December 2, 2013

    Saying that someone’s post is too snarky for your taste invites the retort that – in the words of Frank N. Furter – “I didn’t build him for YOU!”

    Heh. I’ll have to remember that one. I haven’t seen Rocky Horror in ages…

  46. #47 JustaTech
    December 3, 2013

    I would think that more people would be put off these “low T” treatments by the section of the ad that tells you that if anyone else in your family touches the stuff there can be terrible side effects. (Make your children go throught puberty at 8! Turn your wife into a man!) Side effects I experience on a drug I am taking is one thing, but side effects that *only* impact the other people in my life, who get no benefit from the drug? No way.

  47. #48 Nick Theodorakis
    December 3, 2013

    I might expect a blog with the word “insolence” right there in the title to be at least a little snarky. But it’s still way less snarky than PZ’s not-so-secret other blog.

  48. #49 Another Holocene Human
    December 15, 2013

    Re: the term “low T”

    I kind of startled when I heard those commercials because the trans community in Boston in the 1990s called testosterone “T”. There was a lot being trafficked illegally (because the rather patronizing attitude of the medical community at the time towards trans* people made getting approved for hormone therapy exceedingly difficult, but the high rate of hate crimes (assaults, murders) made obtaining hormones a life or death issue), so street drug, street name. There were a lot of issues with shared needles and the like.

  49. #50 Mark R.
    February 6, 2014

    This is not just for the profit I guess. This is reality. A lot of men were diagnosed of having Low-T and I believe that the company just grab the opportunity to help men treat their problems. Nothing is wrong here, as long as the person goes to his doctor first before taking any medicine.

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