Medical Examiner

Is It Time for T?

An ad campaign encourages men to get tested for low testosterone.

Illustration by Charlie Powell.

Illustration by Charlie Powell.

If you watch sports on television, you’re bound to see a parade of “man-vertisements” for beer, trucks, ED drugs like Viagra, and maybe a few ads from Abbott Laboratories’ “Is it LowT?” campaign. The T is for “testosterone,” a hormone so sacred that it cannot be named.

An earlier TV spot featured a paunchy, graying middle-aged male wishing he had more energy and passion for—in this order—golf, sex, family, and friends. The current ad has a basketball theme and includes the oddly phrased question, “Don’t have the hots for hoops with your buddies?” In both versions, a voiceover counsels against blaming these shortcomings on getting older and recommends a visit to a doctor, or Abbott’s website, where one can take the “LowT Quiz.”

As a physician and an aging male, I’d give the entire “Is It LowT?” campaign a failing grade, on both philosophical and clinical grounds.

It gets an F, first of all, for its attempt to transform the natural aging process into a disease state. Growing older is hard enough without feeling like you’ve contracted a chronic illness. I’m not suggesting that we succumb to old age without a fight, but in a youth-obsessed culture, these kinds of quasi-public-service-announcements just create more ridiculous expectations that no one can meet. Older women should have the luxurious skin and perky cleavage of 20-year-old co-eds, and older men should compete in triathlons and have on-the-hour carnal thoughts that trigger gangplank erections. Anything less is giving up.

The LowT campaign also flunks on clinical grounds. The TV ads exhort low-energy golfers and lovers and fathers to “stop living in the shadows,” which is ironic when one considers that our scientific understanding of testosterone in the aging male is quite shadowy. The murkiness starts with the LowT Quiz, a series of nine symptom-based questions, many of which are as vague as they are entertaining. “Are you falling asleep after dinner?” one asks. “Are you sad or grumpy?” says another. My favorite question has to be No. 7 on the list: “Have you noticed a recent deterioration in your ability to play sports?” As a 47-year-old athlete I can affirm that the deterioration in my athletic abilities is not recent, but progressive.

Although the LowT Quiz might seem like it was something dreamed up by Abbott’s marketing department, it’s actually a screening tool developed by gerontologists at the Saint Louis University School of Medicine. But the remarkable similarity between the symptoms of low testosterone and those of natural aging make even the best such tools of limited use. That’s one of the main reasons why the Endocrine Society, the leading professional organization for endocrinologists, doesn’t recommend using them. The LowT Quiz and its ilk cast too wide a net—a large percentage of men who don’t have low testosterone end up testing positive. But perhaps a wide net is what pharmaceutical groups are looking for.

To pass the LowT Quiz (or flunk it, depending on your perspective), one needs to nod “yes” to at least three of the fluffier questions, or to just one of the two more pointed measures: “Are your erections less strong?” and “Do you have a decrease in libido (sex drive)?” An affirmative answer to those last two might sound incriminating, but here again they don’t say much about the quiz-taker’s testosterone level. For a paper published in 2010, researchers involved in the European Male Ageing Study tried to delineate what symptoms correlated most strongly with low testosterone levels and concluded that “the prevalence of even the most specific sexual symptoms of androgen [testosterone] deficiency was relatively high among men with unequivocally normal testosterone levels.” In other words, the mere fact that you’re having impotency and sex-drive problems doesn’t mean you have “LowT.” In fact, the majority of men with erectile dysfunction have NormalT, but abnormal circulation or nerve function.

If taking the quiz gave you performance anxiety, then it’s off to the doctor for something far more objective: a clinical measure of your testosterone levels. We know these peak in a man’s late 20s or early 30s, and then fall at a rate of about 1 or 2 percent a year. We also know that testosterone has more on its mind than sex: It’s also important in bone density, muscle strength, fat composition, and mood. And we know that testosterone levels fluctuate during the day—maxing out around breakfast time and falling by about 30 percent to a trough after dinner.

Beyond those simple facts the shadows begin. Norms for other physiological measures, such as blood pressure, have been well characterized over the years, but testosterone levels tend to have a lot more individual variation. The standard range turns out to be somewhere between a bloodstream concentration of 300 and 1,000 ng/dl. The fact that two individuals can share the same testosterone “profile” (sex-drive, mood, energy etc.) but with a 100 percent difference in testosterone levels—one man at 400 ng/dl, the other at 800 ng/dl—shows how crude the measure can be. One might look at “free testosterone” instead, to see what tiny fraction of total testosterone is not bound to blood proteins, and therefore chemically active and free. But this is hard to gauge with precision, and therefore not recommended as a screening blood test.

Endocrine Society recommendations aside, what’s so unreasonable about following up on Abbott’s kind offer: Take the quiz, and get your blood checked if needed? The answer is that the vast majority of aging males who set out on a LowT pilgrimage will end up suffering from “HighD,” where the D stands for disappointment. Because the LowT quiz is so poorly discriminating, promoting its use means there will be a lot of men with false hopes (“I have a treatable condition! That’s why I fall asleep after dinner!”) at the clinic getting their blood drawn. And the vast majority of them will go through all of that just to be told they have normal testosterone levels. They won’t be able to blame their withering golf game on their testicles.

For those who go through all the testing anyway, whatever the costs and hassle, and turn up positive for LowT, there’s still the question of what happens next. Should we hold a 70-year-old male to the same testosterone standards as a 35-year-old male? Experts disagree on whether the “normal” levels should be scaled back in an age-dependent manner, but their debate raises a central question: Are falling testosterone levels a “mistake” of aging, like arthritis—a complication that should be treated? Or are they a natural, wholesome change, and one not to be tampered with?

We have some prior clinical experience with this, and it’s called hormone replacement therapy. For years we badgered menopausal women to prop up their sagging hormone levels, only to find out—shucks—that doing so increased their risk of breast cancer, heart disease, and stroke. Granted, male andropause isn’t the hormonal free-fall that menopausal women experience, but the concerns about unintended consequences of testosterone therapy are just as real, and include the risk of accelerating heart disease and prostate cancer. There are seasons of life, and the bikini you wore in summer may not work for you in the dark of winter. Hormones critical to our younger life may well have different consequences as we grow older.

The risks of hormone replacement therapy for aging women didn’t become clear until the completion of a very large study called the Women’s Health Initiative. But there have been relatively few studies on testosterone therapy in older men, and those that have been done suffer from small sample sizes and a lack of long-term data, or from not having a placebo arm (which is critically important when you’re dealing with subjective symptoms like energy level and sex drive). In 2004, the Institute of Medicine completed a systematic review of these trials and found no clear evidence of benefit for any of the health outcomes examined, and that includes machismo. Since then there haven’t been any new studies powerful or definitive enough to draw a different conclusion. From the IOM findings came the impetus for “The T Trial,” a large, multicenter study on treating low testosterone levels in older males that began in 2009 and should be finished by 2015. (Interestingly, Solvay Pharmaceuticals, an Abbott Laboratories subsidiary, is one of the trial’s sponsors, providing the testosterone gel.)

While we await results from The T Trial, Abbott’s LowT campaign appears willing to ask men to bravely go where few men have gone before. Why are we seeing ads for a treatment that has unproven benefits and real safety concerns? It started with the broad approval assigned to Abbott’s testosterone replacement product, Androgel, by the Food and Drug Administration. The government gave Abbott permission to sell its product as a treatment for male hypogonadism (i.e. “LowT”), without specifying exactly what constitutes the condition in the aging male. (That’s left up to individual physicians.) But even if the FDA hadn’t approved the drug for this use, the “Is It LowT?” ads would still be kosher, since they’re not directly promoting the treatment. These spots are classified by the FDA as “Help Seeking Ads,” which describe a disease or condition but don’t recommend a specific drug.

If Abbott is really looking to deliver help to the help-seeking—aging males lurking in the shadows—it might buy airtime to encourage older men who’ve lost the hots for hoops to enter The T Trial. That would help us find out whether testosterone therapy for the aging male is good medicine, or just wishful thinking.