There’s a great commercial on television that takes place on a golf course. A well-meaning man, who doesn’t look like he is testosterone deficient, sits next to an ex-football player and ex-baseball player, who look like they have enough testosterone to supply the entire country club. Of course, this leads to the question of whether or not testosterone supplementing agents should be used, with a conclusion that doesn’t leave much to the imagination. This raises a wonderful question on when testosterone therapy should be a concern, and if there aren’t a slew of underlying problems that didn’t make the final commercial cut.
Without going into the synthesis and essential functions of the hormone (careful, this is being written by an endocrinologist), we’ll limit this to testosterone supplementation and when it can do more harm than good. Male testosterone levels naturally drop as they age, and some men have low testosterone levels “just because.” The emphasis on promoting emotional, physical, sexual, and mental health is one guide, and bodybuilding, and muscle development is another. Most underwriting manuals don’t address testosterone and as such underwriting elevated testosterone levels can be murky. An entire cadre of physicians has gone into the “wellness” business, and for men testosterone supplementation is a regular prescription.
Normal testosterone ranges are wide. The labs give the expected range as between 300-1200 ng/dl. But as is the case with many hormone levels in the body, you can feel very normal at either end of the spectrum. With normal muscle development, sexual function, and activities of normal living, a level of 400 ng/dl in one man may be just as adequate as an 800 ng/dl in another. The Endocrine Society as well as multiple other endocrine associations recognize testosterone replacement only for testosterone deficiency or for cases of hypogonadism. It is sometimes used as an adjunct in treating frailty from chronic disease or malnutrition. In real life, a man complains of feeling tired, not being as muscular as he was earlier in life, depressed, or having some degree of sexual dysfunction. He is often prescribed testosterone no matter what the starting level of the hormone was. Testosterone is also a cornerstone in advanced bodybuilding. It may be used with other anabolic steroids not to treat a deficiency but to achieve a more desirable body image or status.
An astute question follows: “Should we look at it differently if there was a true diagnosis or deficiency rather than just used without a specific indication more than increasing the levels?” Assuming there are no other endocrine diseases associated with simple hypogonadism or even what would be considered a low normal value, the simple answer to the question is no. When testosterone levels increase to high levels, there are untoward consequences. High testosterone levels are implicated with increased incidence of myocardial infarction and stroke. There is increased blood clotting. Secondary polycythemia, with high hemoglobin and hematocrit values often result. High testosterone chronically drops HDL (good cholesterol), increases propensity to deep vein thrombosis and pulmonary embolus, may predispose to heart failure, and have an increased incidence of obstructive sleep apnea. While testosterone doesn’t cause prostate cancer per se, existing cancer uses testosterone almost as a fuel, and malignancy speeds up in growth rate. It is one of the reasons in biochemical recurrence or metastatic prostate cancer, therapies that essentially cut testosterone to zero are used (androgen deprivation therapy). Most consider it a contraindication to ever prescribe testosterone to those with a history of breast or prostate cancer.
Yet another question in underwriting comes up with concomitant anabolic steroid use with testosterone therapy. Many bodybuilders use both, which in addition to all the complications above will include liver failure and liver cancer. While we generally will not ensure men known to be taking anabolic steroids, detecting which clients may be users is a quandary. Lab testing may detect this, but we often don’t get specific labs on everyone we underwrite. Looking for low HDL with high liver function tests and secondary polycythemia can be a strong hint in that direction.
Replacement of testosterone in men who are deficient with levels that fall within the normal range during therapy pose little underwriting risk from that. Those however who show high testosterone levels over what would be needed in simple replacement, who show increasing weight and muscle development and perhaps increasing serum creatinine levels, who have a tendency toward the cardiac and clotting phenomena that increased testosterone promotes, or those who have secondary polycythemia, high liver function tests or decreasing HDL levels have to be underwritten with caution, and underwriting conservatively (or questioning specifically) is a wise option.