Testosterone therapy's big week: One urologist's perspective
On Feb. 21, 2017, five testosterone therapy (TTh) articles—four of which contained results from the Testosterone Trials—were published in JAMA and JAMA Internal Medicine. This was arguably the most important week ever for the science of testosterone therapy and its impact on men’s health. Although the totality of these research studies showed impressive benefits and reassuring safety evidence, media coverage followed its well-worn pattern of focusing on weak evidence of risk while largely ignoring major positive findings that could well alter medical care. This repeated distortion of the science regarding testosterone has been recently analyzed by my colleagues and me in an article entitled, “Overselling hysteria” (EMBO Rep 2017; 18:11-17).
What should urologists know about these five articles? Two were prospective placebo-controlled trials that demonstrated clinically meaningful improvements in areas where TTh benefits have not been widely recognized, namely improvements in bone density and unexplained anemia; one was a very large observational study that demonstrated an impressive reduction in cardiovascular events; one trial was neutral with regard to cognition; and one provided equivocal evidence regarding coronary atherosclerosis.
Also see - Men’s health: A forgotten topic
Let’s address the allegedly bad news first. In a cohort of men participating in the Testosterone Trials, 138 men 65 years of age and older (mean age, 71.2 years) were assigned to either 1 year of T gel or placebo gel (JAMA 2017; 317:708-16). Coronary computed tomography was performed at baseline and after 1 year. The primary result was that the increase in non-calcified coronary plaque volume was significantly greater in men who received T than in those who received placebo. Coronary calcium scores were no different between groups, and in fact were numerically reduced in the T arm at 1 year.
While it sounds bad that plaque volume increased more in men who received T gel, the results are difficult to interpret since mean baseline plaque volume was much higher (>50%) in the placebo group (317 mm3) than the T group (204 mm3). At the end of 1 year, median volume in the placebo group was 325 mm3 compared with 232 mm3 in the T group. Although the change in volume from baseline was slightly greater in the T group, that difference is overwhelmed by the magnitude of the differences between groups.