Does One Size Fit All?

One size fits all approach to medicine never works.  It doesn’t work in traditional allopathic medicine and it doesn’t work in natural medicine.  Whether it is natural or not, a physician cannot treat all patients the same.  This seems logical too most, but this is a tunnel of thinking that medicine cannot get itself out of.  The reason for this spiral of thinking is the high volume, low quality business constraints of the current business model.  But, this not the purpose of this post and will not be discussed further.

 

The use of Testosterone replacement therapies have increased by 500% over the last 2 decades.   This increase use, based on marketing-based medicine, has brought about the commonly seen marketing phrases—“anti-aging”, “fountain of youth”, “ever young”.. present everywhere.  This has led to inappropriate expectations by both patients and their doctors.  The reason?  Because the therapies are based on marketing and beliefs that neither of which have a foundation in the scientific evidence currently available.  A belief is great if it is based on a foundation of solid data.  But a belief based on no data is a fools errand and a belief in nothing at all.

It is the responsibility of a physician to critically analyze data—not to take opinion statements or marketing at face value, but to question everything irregardless of the source.  The Institute of Medicine reported in 2001 that it takes an average of 17 years for science to make it into clinical practice.  Stated another way, the average physician practices at a level that is 17 years behind the current scientific knowledge.  A recent report found that a majority of physicians get their information from wikipedia.  Neither of these point to a critical assessment of data by physicians.

 

This brings me to a very recent publication (1.29.14) on Testosterone therapy.  This article was published via an online peer-reviewed site called PLOSone.  This article was a cohort of 55,593 men.  This study was merely a review of data collected from 2008 to 2010.  This was not a randomized controlled study.  There was little information on the method of hormone testing done, the criteria of diagnosis directing therapy, nor the dosing of therapy.  The authors of this study found that there was a significant increase risk of early non-fatal MI’s in men > 65 years of age in those with pre-existing cardiovascular disease and those without.  This study also found an increase risk of non-fatal MI in men < 65 years of age that had pre-existing cardiovascular disease but not in those without.

 

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This study follows 3 previous studies that have been recently published that showed an increase risk of cardiovascular disease and events with Testosterone therapy in men.  The first was a study of 209 men > 65.  This study was stopped early because of increased adverse cardiovascular events in those men treated with Testosterone.  The second study was a meta-analysis of 27 studies published in 2013.  This study looked at mainly older men and found an increase in cardiovascular events.  What is interesting about this study is that the authors found that the funding source seemed to change the outcome.  Those studies funded by the pharmaceutical industry found no increase in cardiovascular adverse events, but those studies not funded by the pharmaceutical industry did find an increase risk with Testosterone therapy.  This points to problems in many of the studies published today—bias.  The 3rd study was published in 2013 and this study of men  > 60 at the VA in Virginia found an increase in cardiovascular events with Testosterone therapy.  Eighty percent of these men had pre-existing cardiovascular disease.

 

That is 4 studies that show increased cardiovascular risk with Testosterone therapy in men.

This sits in stark contrast to studies that show low Testosterone plays a role in the genesis of cardiovascular disease.

 

The take home from this recent publication is that a one size fits all approach does not work.  Testosterone therapy, whether it is Testosterone cream, shots, or pellets, in a one size fits all approach never works.  It didn’t work with women in menopause and it won’t work in men.  This was learned the hard way in the Women’s Health Initiative in 2001.  It is apparent that physicians are learning the same hard lessons.  Unfortunately, patients will suffer as a result.

 

There has been a massive increase in the prescription use of Testosterone therapy in men old and young.  In many men, this therapy occurs without appropriate evaluation, no evaluation at all, and poor follow up.  Most of the therapies employed amount to no more than simple doping.  Don’t get me wrong, low Testosterone is an enormous problem in men today.  I document this in my upcoming book “Man Boob Nation”.  However, low Testosterone is the effect not the cause.

 

Is Testosterone safe? Of course it is.  Do some men benefit from Testosterone therapy? Yes.  Does Testosterone therapy have serious risks?  Absolutely!  Does a one size fits all approach work for Testosterone therapy?  Never.

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