The Sunday Times 24 November 2013
THOUSANDS of men are receiving testosterone on the NHS to combat the male menopause even though there is little evidence it has any health benefits and may even increase their risk of a heart attack or stroke.
In recent years testosterone has been seized upon by overweight, middle-aged males hoping to boost muscles, energy levels and sex drive. More than 300,000 NHS prescriptions for it are issued each year, a fivefold increase since the early 1990s. Many more men are receiving it privately.
According to the Health and Social Care Information Centre, the cost of testosterone products to the health service increased by £4m between 2011 and 2012, taking the total outlay past £16m last year.
In addition, an unknown number of treatments are sold through the internet or private gyms and fitness centres, where the patches, gels and injections, along with other anabolic steroids, are regarded as an effective way of turning fat to muscle.
The boom in hormone replacement therapy (HRT) is largely due to the realisation that overweight or obese men suffer depressed testosterone production.
About one in five British men aged over 40 fits into this category. For them extra testosterone is attractive. It is better than Viagra as a sex drive booster, turns fat back to muscle and improves strength and bone density. Short-term use appears to reduce cholesterol and the risk of diabetes.
In America, advertising has focused on fatigue as a symptom of hormone deficiency, and 5m men are now using testosterone gel or undergoing injections.
However, many men are prescribed the drug before real evidence of low testosterone has been established.
A testosterone level of less than 8 millimoles per millilitre of blood is considered dangerously low, and 12 is thought healthy, but there is uncertainty about the group with levels of 8–12. For them the benefits of HRT are much more dubious.
“Testosterone doesn’t decline in healthy old age; the only reason it declines in some people is that they are either ill or they are obese,” said Richard Quinton, a senior lecturer in endocrinology at Newcastle University, who has expressed concern about over-prescribing in the NHS.
“Its use is being promoted to GPs by a miscellaneous bunch of misfits who are trying to blur the distinction between testosterone deficiency and being fat and unfit,” he said. “Many of those receiving it may be risking serious harm in exchange for illusory benefit.”
The hormone increases the oxygen-carrying capacity of the blood by increasing red blood cell production. However, it has been suggested that the blood then becomes thicker, making fatal circulatory disorders more likely.
A two-year US study of almost 9,000 men has shown that those taking HRT have a 30% higher risk of heart attack or stroke than non-users.
Ugis Gruntmanis, professor of endocrinology at the University of Texas Southwestern Medical Center said the men in the study had a mean age of 60. “These results are very worrying,” he said. “At the start of the trial the [user] group actually had fewer risk factors for heart disease and were younger.”
He said the results, published in the Journal of the American Medical Association, reflected similar findings from a 2010 six-month study of 209 men with an average age of 74 in Boston, half of whom received testosterone.
Although the hormone improved strength, the trial was halted after 23 of those given it suffered heart attacks.
Doctors fear the scare will mirror the HRT panic for women a decade ago, which led many patients who could benefit from HRT to stop using it.
Bayer HealthCare, which manufactures testosterone gel and the injections, is believed to have more than 60% of the UK market.
The company said it was evaluating the data from the Dallas study but no evidence of harm had been associated with Bayer products.
British drug regulators have been caught unawares by the testosterone phenomenon. The National Institute for Health and Care Excellence, which normally produces guidance on medication, has remained silent.
NHS England, which is in charge of drug policy, simply suggested that doctors discuss the treatment with patients.
The British Society for Sexual Medicine said one in five men over 40 suffered depressed testosterone production, usually as a side effect of obesity.
Geoffrey Hackett, its former president, said American fears about heart disease were unfounded. “If you don’t give it, these men remain obese and die younger,” he said.
Correction: In the original version of this article we stated that the men taking HRT who participated in a US study had a mean age of 50. This should have been 60.