Chapter 101
The Risks of Testosterone Treatment
At see.nf/trisks I go into possible problems in detail, including sexual infidelity, more frequent arguing and aggression, and the most ironic side effect: testosterone deficiency. Bodybuilders’ testicles shrink because the extra testosterone signals the brain to dial down natural production, causing the body to suffer an even greater deficiency if testosterone therapy is ever discontinued. This creates a profitable vicious cycle of dependence.
Testosterone can also stimulate the bone marrow to produce more red blood cells, which is good if you’re anemic, but if the blood is flooded with too many red blood cells, there is a risk of heart attacks and strokes. That is why the “Testosterone in Older Men” study had to be stopped because there were ten times more heart problems in the testosterone group than in the placebo group. Since there have been black box warnings about the serious side effects, such as the one stating that testosterone “poses a risk of serious and potentially life-threatening cardiovascular (heart and blood vessel) problems,” testosterone prescriptions have dropped sharply.
A commentary in a leading anti-aging magazine compared testosterone replacement therapy to the emperor’s new clothes and noted that the topic remains “astonishingly controversial.” What else would you expect when a multibillion-dollar industry is at stake? An analysis of popular YouTube videos on the subject shows that massive amounts of misinformation are still circulating, yet a systematic review of more than 150 randomized controlled trials concluded: “We found no population of normal men for whom the benefits of taking testosterone outweigh the risks.”
Benefits and risks of PSA screening for prostate cancer
Testosterone therapy, surprisingly, does not worsen an enlarged prostate, but what about prostate cancer? Testosterone’s role in prostate cancer has been known since the 1940s, when it was found that surgical castration led to a dramatic regression of tumors. To this day, testosterone suppression is widely accepted as first-line treatment for symptomatic metastatic disease. The question of whether testosterone causes prostate cancer or merely accelerates it does not arise, because autopsy studies show that in about one third of all men over 30 and two thirds of all men over 60, tiny prostate carcinomas are already growing—whether they know it or not. That is why guidelines recommend rectal exams and PSA screening before testosterone therapy. What is there to say about prostate cancer screening in general?
Although 64 percent of 60-year-old men have an undetected prostate carcinoma, the lifetime risk of a prostate cancer diagnosis is only about 11 percent, and the risk of dying from it is 2.5 percent. Most men therefore die with their prostate tumor, not from it. Many never even know about their condition their entire lives. That is one of the problems with early detection: Many prostate carcinomas found during screening might never have caused harm if they had remained undetected. Still, not all men are that lucky. Nearly 28 000 die of prostate cancer every year (on average at age 80). So should you get the PSA test or not?
The U. S. Preventive Services Task Force advises against routine PSA screening, as do the American College of Preventive Medicine, the American Academy of Family Physicians, and the majority of medical professional societies in industrialized countries worldwide (36 of 42). The USPSTF, however, changed its position in 2018 to state that for men between 55 and 69 “the decision to be screened for prostate cancer should be an individual one,” thereby joining the “shared decision-making” of the American Urological Association, the American College of Physicians, and the American Cancer Society. In other words, men should be informed about risks and benefits and decide for themselves. However, according to the latest USPSTF recommendation, those who are undecided and do not clearly opt in favor of screening should not be screened.
Recently, an international panel of experts concluded that doctors need not feel obligated to raise the topic systematically, because most men would decline PSA screening in light of the clear harms and the small and uncertain benefit. However, everyone has to decide for themselves. Let’s go through the numbers.
Similar to the 92 percent of women who overestimated the benefit of mammography by at least tenfold or simply could not say, 89 percent of men likewise vastly overestimated the benefit of prostate cancer screening or had no idea. Most thought that 50 prostate cancer deaths per 1000 regularly screened men could be prevented, when in reality it’s closer to one. But aren’t a few blood tests worth it for a 1-in-1000 chance of not dying of cancer? The downsides of screening are more than mere inconveniences.
With PSA screening, about one in seven men tests positive, yet in two thirds of cases the result of the subsequent biopsy is normal. So out of 1000 regularly screened men, about 150 get a false alarm and are unnecessarily biopsied, which can lead to minor complications such as pain and bloody ejaculate or, in about one percent of cases, to more serious complications such as blood-borne infections requiring hospitalization. Overdiagnosis, however, causes the greatest harm. Unnecessary biopsies are bad enough, but they are nothing compared with unnecessary cancer treatment.
Large randomized trials suggest that 20 to 50 percent of men diagnosed with prostate cancer would never have had symptoms during their lifetime. Screening doesn’t help them one bit, but it may land them on the operating table unnecessarily. About 3 out of 1000 men die during or shortly after a radical prostatectomy. That could explain why prostate cancer screening does not reduce all-cause mortality. For every life saved, another is extinguished, because of a cancer the person would never have known about.
Another 50 out of 1000 experience serious surgical complications. Even if the operation goes smoothly, about one in five develops long-term urinary incontinence and has to wear pads, and most—two thirds—suffer long-term erectile dysfunction. Most men also get that after radiation therapy, which in nearly one in six additionally causes long-term bowel problems such as fecal incontinence. If that treatment saves your life, it would be worth it, but it is 50 times more likely that instead a cancer will be overdiagnosed that never would have caused problems. In that far more likely case, you get harm and no benefit. But it’s like mammography—those who were harmed the most are the most likely to believe they were helped.
Natural ways to increase testosterone
The American Urological Association, the European Association of Urology, and the Endocrine Society, the oldest society for hormone research (so old that it used to be called the “Association for the Study of Internal Secretions”), all recommend lifestyle change as the first choice for treating low testosterone levels. In other words: treating the causes.
In older men, low testosterone is mostly the result of obesity and its accompanying conditions and can often be reversed by losing weight. An enzyme in body fat converts testosterone into estrogen. Losing just 5 percent of body weight results in a significant increase in testosterone levels. The testosterone levels of men who lost more than 15 percent rose by an average of more than 150 points (ng/dl), and in those who lost about 30 percent of their weight (through bariatric surgery), the increase was about 250 points.