Thursday, October 27, 2011

I saw Mr. L the other day. He was one of my oldtimer patients (not in terms of age, but I'd been seeing him for a while). And one of the things he said struck me as an odd, but surprisingly accurate, statement.
"You don't really believe in the stuff you supposedly peddle, do you?"

I had been seeing him for his diabetes for years. And on a more recent visit, he complained of issues with erectile dysfunction and low energy. And so when I offered to check his testosterone levels, he was quite keen on it. Nothing really jumped out on his history; he just occasionally has trouble keeping his erections during intercouse and his libido was a bit decreased. Otherwise, his morning erections, and during masturbation, seemed normal (yes, awkwardly personal, but very helpful questions to ask). He denies any gynecomastia, change in shaving habits. As with many of my diabetes patients, he is obese and has the typical habitus of someone who may have sleep apnea.
As it turns out, his total testosterone was slightly low at 314 ng/dL (normal more than 350). And so we had a discussion about testosterone replacement. He was quite keen on trying something, having seen the numerous TV ads (you know which one I'm talking about; the one with the guy talking to his shadow). And yet he sensed my uncertainty, which I did not attempt to hide.

I belong to one school of thought. The other side of the fence. There is a reason why the normal range for many hormonal tests is wide. They are based on what is deemed to be a normal population, with all our indivdual variations. And the nature of many hormones is that they fluctuate. When it comes to testosterone, there is an age-related decline, as well. And so, it is not too uncommon to have levels sometimes being a bit low. Frequently, blinded studies show little benefit of replacement for many of these borderline patients. However, you'd not believe this, seeing the numerous TV, magazine and newspaper advertisements, suggesting that medication A or B will make you feel like a new man. That if you are tired, or lack the drive you did when you were 20, or struggle with low stamina and weight gain, then it MUST be the low testosterone (heck, maybe I should get MY levels checked. That all sounds like me!). Pharmaceuticals is after all, a multi-billion dollar industry.

While cautious therapeutic replacement trials should be safe so long as things are carefully monitored, I'm of the opinion that the drug companies are already making far too much money, and if someone is not going to feel any better being on their medication, I'd usually discourage things. I'm open to it, but I'd usually not push it. Be it for borderline hypogonadism, or 'hypothyroidism' with a TSH of 5.2, or something similar. Perhaps it is ironic then that a board-certified endocrinologist is much less keen on starting patients on hormone replacement, than many of my general practitioner colleagues.

And so, I left the final decision on whether to start testosterone or no up to him. After checking into the cost of the medication, and looking up some (reputable) medical websites, it appears that he agreed with me. He said no.


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