Are Testosterone Injections a Cure for Middle Age?

testosterone
 Illustration by Michael Byers

A 50-year-old guy goes to  the doctor with the symptoms of, well, being a 50-year-old guy. He’s overweight, sleeps poorly, and has less energy, as well as a lot less sex, than he once did—and all of this has made him depressed. Blood is drawn and his testosterone level is normal but on the low side. Doctor’s orders: Join a gym. Lose weight. Eat better.

This confounds Tim Church, M.D., a preventive medicine researcher in Dallas. That’s because he knows from experience how few fatigued, out-of-shape guys actually succeed trying to follow that common-sense advice. “If we just tell him to go to the gym, it’s almost guaranteeing failure,” Church says. “Why wouldn’t we give him something to help?”

For a growing number of physicians, that something is testosterone. The hormone, of course, has long been prescribed to men whose levels drop below normal (and has been doled out haphazardly by low-rent doctors, giving it a bad reputation). But a new wave of sophisticated anti-aging specialists are deploying T in a different way, as a kind of jump start designed to spur lifestyle changes—even if a patient’s levels fall within the normal range.

“I’ve seen an uptick in my practice,” says Joseph Raffaele, M.D., an age-management doctor who runs a boutique clinic in New York City. Give lethargic, depressed, or low-libido guys a jolt of T, Raffaele says, and they have more energy. More energy means they’re more likely to make it to the gym. That begets increased muscle mass and fat loss, which increases natural testosterone production. In other words, a boost of testosterone triggers a virtuous cycle that can give men a second chance at younger years.

Not only that. “They lose fat around the middle and all their numbers improve—blood pressure, cholesterol,” Raffaele says. “All the things doctors worry about for patients in their 40s and 50s.”

This thinking represents a sharp break from conventional medicine. Yes, testosterone affects a range of bodily functions, including mood, red blood cell production, muscle growth, bone density, and sexual arousal. But the hormone hasn’t been considered a cure for aging. Frances Hayes, M.D., an endocrinologist at Massachusetts General Hospital in Boston and a leading authority on hypogonadism (clinically low testosterone) hasn’t seen evidence that treating a guy whose T is on the low side of normal translates into any life-changing vitality. (The numbers vary depending on the lab doing the testing, but the normal range for a guy 19 to 39 years old is 264 to 916 ng / dL.) According to Hayes, even men whose testosterone levels fall in the just-below-normal range can expect mediocre results. “I’ve had plenty of patients who say to me that they don’t have the energy to go to the gym,” she says. “In my experience, when we bring their testosterone levels up, they still don’t seem to have the energy.”

Hayes, like most of her endocrinology peers, argues the better, safer way to boost T for a guy with the middle-age blues is the classic prescription of weight loss, de-stressing, and eating well. To wit: A 2017 study published in the Journal of Clinical Endocrinology and Metabolism shows that dropping 10 percent of your body weight can translate to an 80-point bump in testosterone.

Both sides of the debate were looking for clarity from a first-of-its-kind study funded by the National Institutes of Health. The T trials followed 790 men ages 65 and older with below-normal testosterone for one year.

The results, released this year, were a mixed bag. Testosterone scored points for improving erections, sexual frequency, anemia, and bone density. It didn’t improve cognitive performance (the brain, like the rest of the body, is loaded with testosterone receptors, so it was an attractive theory), and the mood boost was marginal.

Some of the researchers were surprised that added testosterone didn’t boost energy. They had used a standard gerontology measure: how fast the seniors stood, then how far they walked or jogged in six minutes. Those on T outperformed the placebo group but only barely.

“That’s one of the things that’s really perplexing,” says Shalender Bhasin, M.D., an endocrinologist at Brigham and Women’s Hospital in Boston, who worked on the trials. “Despite clear evidence of testosterone’s effect on muscle mass and strength, why has the improvement in physical function been so difficult to demonstrate?”

Raffaele is unfazed by the results, pointing out that the men in the study are considerably older than the patients he sees. “For these men, the horse is already out of the barn,” he says. “The researchers are trying to intervene in the aging process 20 years too late.”

Until there’s a multiyear study on younger men, those who opt for treatment accept an element of guinea pig status. Doctors are particularly concerned with potential heart problems; in 2015, the FDA required testosterone labeling to include a warning about a possible increased cardiovascular risk. It also may be linked to sleep apnea, stimulating noncancerous prostate growth and blood clots, among other things, says Debabrata Mukherjee, M.D., the chief of cardiovascular medicine at the University Medical Center of El Paso, in Texas.

And it’s expensive. Unless you’re technically hypogonadal, insurance won’t cover it, so men must pay somewhere $50 to $200 a month for treatments, not including initial testing fees.

Critics contend the pro-T doctors have chosen the wrong enemy: aging itself.

“Hormones serve an evolutionary purpose and the drop may be normal,” says Darby Saxbe, a clinical psychologist at the University of Southern California. Testosterone peaks in a man’s 20s—prime mating years—then goes on a long, slow decline. Her research found that a man’s testosterone decreases if his partner is pregnant; the more children he has, the lower it is. Coincidentally, men with lower testosterone are more attentive fathers and better partners. In middle age, maybe you’re not supposed to be sowing your wild oats.

Yet the anti-aging movement exists to defy evolutionary decline. Raffaele is comfortable boosting the T levels of his patients to those of men half their age. After all, he says, “Who doesn’t want to feel like a 20-year-old?”

Plus, if testosterone treatment does spur healthy changes, men may avoid or delay some age-related diseases. Shedding weight and boosting happiness, for example, are great for the heart. And the effects may be fairly direct. Brent Muhlestein, M.D., a cardiovascular researcher in Salt Lake City, used patient data from the Intermountain Medical Center to complete two observational studies. They revealed that older, low-testosterone patients who had undergone T therapy suffered fewer heart attacks and strokes. “If placebo-controlled trials confirm those positive results,” Muhlestein says, “then we’ll use testosterone as a drug to treat our heart disease patients.”

The Endocrine Society is set to release new guidelines for testosterone in 2018. The safe money says it’s not going to widen the T-treatment threshold, which will keep the anti-aging doctors outside the medical mainstream for now. But that won’t stop plenty of guys who aren’t giving up on feeling young.