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Do risks outweigh benefits of low testosterone treatments? Maybe

There are billions of reasons we see all those TV ads about sexual dysfunction and low testosterone.

Millions of Americans struggle with these conditions, and drugs that help relieve symptoms have become much more commonplace.

Sales of Low-T drugs alone increased five-fold between 2000 and 2011, to $1.6 billion in the final year, according to Urology Times, and the pharmaceutical marketing campaign was so successful, it’s now taught at Harvard Business School.

It begs the question – How helpful are these drugs?

That depends.

“In the aging male population that we treat here, a lot of men have it but not everyone should be treated with testosterone (replacement). We have to very carefully weigh the cost and benefit,” said Amy O’Donnell chief of endocrinology at Veterans Affairs Medical Center in Buffalo and a clinical associate professor with the University at Buffalo School of Medicine and Biomedical Sciences.

First, doctors must determine whether symptoms of Low-T – low energy, low sex drive, erectile dysfunction, weight gain – can even be attributed to the condition. Depression, thyroid problems and sleep apnea can cause the same symptoms.

“If it looks like low testosterone is your problem, we’ll try giving you medication for a couple of months and see how much difference it makes,” O’Donnell said. “If we try medication and the person still doesn’t feel well, it might be something else. If it doesn’t help, the risk outweighs the benefits.”

It’s also possible to have Low-T and display no symptoms.

“If a person doesn’t feel the symptoms but they’re complaining about something that could be a symptom, they don’t need to take testosterone,” she said. “There’s no benefit. All you’re working with is risk if there’s nothing to improve their symptoms.”

For more on the Low-T treatment and risks, click here to read a story from the Mayo Clinic.

O’Donnell spoke to me this week during an interview for this weekend’s In the Field Feature in WNY Refresh.

She is an expert in metabolism who mostly treats veterans and their spouses with diabetes, thyroid problems and low testosterone.

Below are excerpts from my interview with O’Donnell that I didn’t have room for in the print edition:

Q. Do you see any changes on the horizon when it comes to diabetes treatment?

It could change as we get closer to personalized medicine. There’s so many different factors and genetic influences with diabetes. Now we have all sorts of different drugs that treat it and each one works differently. There’s no way to predict who’s going to respond best to one drug or another. Sometimes, you put somebody on one drug and that’s their answer for diabetes, and you put somebody else on the same drug and they get all the side effects but none of the benefit.

Q. So soon after diagnosis, is it pretty much trial and error?

Not so much soon after diagnosis. Most people early on respond to the same medications. But living years and years with diabetes, it becomes more difficult to regulate. As you have to think about having to add medications ... the first-line and second-line treatments are pretty much the same for everybody. But after about 10 years, they seem not to work so well anymore and more specialized medications are required. These are the things that may have more serious side effects, but they’re often worth taking if they fix your diabetes.

Q. What makes for fast or slow metabolism and which is better?

(With a laugh) Normal is the best. Usually, when you think about metabolism you’re thinking about thyroid action. That’s the main hormone that regulates metabolism. But insulin action is part of metabolism and so are other glands. It’s part digestive tract, part the hormones.

With a normal metabolism, you feel well. When you get a good night’s sleep, you feel refreshed. You have energy to do what you need to do. When you eat, your body handles the food you eat well. Digestion works well.

Q. How do our glands work?

It depends on the gland, but if you use the pancreas as an example, diabetes is just not how much insulin the pancreas makes, but how well your body uses the insulin. With diabetes, people have insulin resistance, where their insulin just doesn’t work properly. Not only is the pancreas not making enough insulin to overcome that resistance when somebody has diabetes, but there are things that can change that. Exercise improves insulin resistance so insulin can work better. In that way, it helps your metabolism. Following a healthy diet means you don’t need as much insulin to cover the food than if you were eating a large amount of carbohydrates, for example.

So diet and exercise help.

Another thing I would say – and I explain this to patients all the time – is just because you have the symptoms of an endocrine disorder doesn’t mean you have an endocrine disorder.

The symptoms of hypothyroidism – feeling tired, cold, constipated – there are all sorts of different reasons you can have those. The symptoms of low testosterone – low energy, low sex drive, you can have those for all sorts of reasons. I do the blood work. Even though the test is sometimes a little bit abnormal, fixing it might not be the answer to their symptoms, so there’s a lot of trial and error to it.

Q. What tends to get people into trouble with their diabetes so they have to come see you and your colleagues?

If they require intensive insulin therapy, multiple daily injections or insulin pump therapy. If their diabetes has become more severe over time, which is unfortunately the usual course of diabetes. The first line medications aren’t as effective, so their diabetes is out of control. Some of the newer, riskier, more expensive medications – some of which are restricted – may require some expertise to prescribe because of this risk-benefit ratio. We may be referred patients for that reason. Anybody can prescribe insulin but it can become complicated in terms of what’s the best way to prescribe insulin, so they may be referred to us for help with that.

Q. What advice would you give to patients who become prediabetic and diabetic?

The main treatment would be diet and exercise for Type 2 diabetes. Even with advance diabetes, it’s still the most important component, but with prediabetes, diet and exercise can delay, and maybe even prevent, the onset of diabetes. It’s not just what you eat but to be mindful of what you’re drinking. Some people start getting extra symptoms of diabetes and start getting thirsty, and start drinking soda pop or sweetened tea. Things with sugar just makes it worse.

Q. Do you see the results of people who say, “I can just keep doing what I’m doing?”

Old habits are hard to break. A lot of the patients referred to us do have compliance issues. One of the things we try to do is figure out what the barriers are to compliance and figure out if there’s anything we can do to make it easier to comply. If someone is visually impaired and has trouble checking their blood sugar, we can get them a talking meter. If someone has a tremor or loss of feeling in their hands and has trouble drawing up insulin, we can get them an insulin pen. If somebody says, “My finger hurts. I can’t keep checking my blood because those lancets I keep having to poke my fingers with hurt too much,” we can get extra fine lancets. If somebody says, “I hate this. I can’t stand dealing anymore with this chronic disease, I’m sick of it,” we have a special psychologist who deals with chronic diseases and can offer behavioral therapy for that. We try to address the complaints by making it easier to comply.


Twitter: @BNrefresh

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