Testosterone replacement and heart disease.
March 2015, The FDA mandated that all
manufacturers of testosterone place a WARNING on all approved
prescription testosterone products notifying patients of the
possibility of increased risk of heart attacks, strokes and
death in patients taking testosterone and that testosterone
therapy is only approved for hypogonadism that has been caused
by a specific “medical” condition and not solely due to age-
related low testosterone.
This was a big move by the FDA!!
The current controversy regarding testosterone and heart disease
began in 2013, when JAMA published an article indicating that
there may be an association between testosterone therapy and an
increase in heart attack, stroke and death.
Later, in 2014 another major article came out with similar
findings. Since this time, the media, public interest and class
action suits have intensified.
There has been much debate on the validity of these statements.
The Mayo Clinic Proceedings published their findings in
the February 2015 issue- Morgentaler et al:
The authors of the Mayo study found that in summary, there is no
convincing evidence of increased cardiovascular risks with
testosterone therapy. On the contrary, there appears to be a
strong beneficial relationship between normal testosterone
levels and cardiovascular health that has not been widely appreciated.
The mayo study concluded that the studies that indicated
cardiovascular risks had serious methodology concerns and that
the end points were in some circumstances not statistically valid.
The medical community is conflicted about what to do with testosterone and patient health. Because the facts are unclear and there are few, if any well designed studies looking at cardiovascular health of men on long term testosterone therapy, doctors have “pushed away” men on testosterone, not too mention men on anabolic steroids. We are in bleak times, to say the least.
The controversy lies in the fact that androgen therapy can lead to increased heart disease risk for men!
In my professional opinion, and after taking care of
thousands of men on testosterone since 2005, including men on Anabolic/Androgenic Steroids AAS, I worry that some men are at risk for heart disease related to testosterone and AAS. I have seen men as young as 25 years old undergo Coronary Artery Bypass Graft- GABG in addition to hundreds of men receive stents, secondary to blockages in their hearts. The truth is that men on testosterone and AAS have to be properly cared for and monitored with greater clinical vigilance! The bottom line question is; what man is at risk for androgen related heart disease and how do we protect him? The mechanism-of-action related to how testosterone and androgens, e.g., AAS cause heart disease is unknown, but there are a number of obvious cardiovascular risks that are well known. We have to address these! I will list what I see to be the “culprit(s)” :
1. LDL lipids increased, including the dangerous subtype(s) of LDL.
2. HDL lipids decreased.
3. Hypertension caused by testosterone or AAS.
4. Hemoglobin/Hematocrit increase- Polycythemia.
5. Direct adverse effects on the coronary artery endothelial cellular bed.
6. Hypercoagulable state(s) -secondary to androgen and or metabolites such as, dihydrotestosterone, estrogens, progestins and other metabolite hormones that can lead to arterial blood clots. Addition to Deep Venous Thrombosis-DVT and Pulmonary Embolism-PE.
7. Obstructive Sleep Apnea- a known consequence secondary to androgen use. Can lead to LVH.
8. Left Ventricular Hypertrophy-LVH. Enlarged heart secondary to androgen use. Can lead to heart failure.
9. Ancillary agents like aromatase inhibitors and other concomitantly used medical agents commonly used with AAS that can increase cardiovascular disease risk. (Future article).
PLEASE PRINT THIS ABOVE LIST AND BRING IT INTO YOUR DOCTOR FOR DISCUSSION!
I WILL ADDRESS TREATMENT PROTOCOLS IN MY NEXT ARTICLE.
Once a man is diagnosed with “Low T” and an identified medical
cause, e.g., brain disease like a pituitary disorder, diabetes,
damage to the testicle or in many cases secondary to Anabolic
Steroid Induced Hypogonadism-ASIH, then a physician who is an expert
in treating men with testosterone should initiate treatment with
the lowest possible dose of testosterone and monitor him closely
for heart disease, medical disease’s associated with androgen replacement,
psychological abnormalities and prostate
disease (these will be medical topics covered in future articles). The complex and multi-factorial nature of managing men on testosterone is humbling and needs to be taken very
seriously. I have seen the beautiful quality of life that
testosterone can bring a man who is managed properly on
testosterone. On the flip side, I have seen the tragedy of
what can happen to men who have used testosterone and or AAS
inappropriately and unsupervised by a qualified physician.
Testosterone therapy is not some trend that will come and go like bell-bottom pants. It’s here to stay. There are no agents in the pipeline that can do for men what testosterone does period! And this is why we have not been able to push this crude agent aside. It’s time to make testosterone treatment a sub-specialty of medical practice.
This is what I have done since 2005.
If you are on testosterone, AAS or considering starting testosterone/AAS,
please learn about the potential risks and seek consultation
with an expert physician who understands the current-day risks
vs benefits of these powerful medical agents.
To follow the discussion on the article click here
Thomas O’Connor, MD
Board Certified Internal Medicine since 2005
Clinical Instructor of Medicine
Department of Medicine University of Connecticut School or Medicine