Too much testosterone can be costly in older men

The most dangerous drug-drug interaction, joked an old professor during a med school pharmacology lecture, is testosterone and ethanol. The class cracked up as he conjured up images of young men binge-drinking and doing crazy things. Today the demand among older men for testosterone replacement therapy is on the rise. However, the risks of raising levels of this popular hormone, particularly in this population, can outweigh the benefits. Older men who take testosterone aren’t so much at risk for getting into bar fights or racing their cars as much as they are for heart attack, stroke and cancer.

Testosterone prescriptions are up more than fivefold in the past decade, reaching 5.3 million orders and a market of $1.6 billion in 2011.

A recent trial of testosterone in older men with mobility limitations was terminated early because of an observed increase in the rate of heart attacks within the treatment group. This week another study showed that older men with heart problems had a 29 percent higher risk of death if they were also undergoing testosterone treatment, according to the Journal of the American Medical Association.

Robust levels of testosterone can result not only in heart disease and stroke, but also agitated aggressive behavior, high blood pressure, headaches and liver damage. In addition, normal prostates gradually enlarge in response to normal levels of testosterone. Prostate cancers may be stimulated as well. Particularly high levels of testosterone further increase the risk of both.

Testosterone levels can certainly be too low. Signs and symptoms include decreased sex drive and reduced performance; hair loss; low motivation; depressed mood; waning muscle mass; thin, weak bones; and increased body fat. The increased body fat from low testosterone combined with a reduced drive to exercise can be a contributing factor in obesity, diabetes and sleep apnea.

The high-profile fight against obesity has spawned a social revolution aimed at trimming down. It comes down to how many calories we put in our mouth and how many we burn. This column has often covered large-scale corporate initiatives to leverage the "feeding frenzy" ranging from the latest diet plans like the "paleo" (meat and veggies) to fitness programs like CrossFit to CorePower, a yoga franchise working to muscle in on the fitness industry. By the way, how many yoga studios can this town support?

In increasing numbers, people want to trim down to look better, feel better, stay healthier and live longer. It should come as no surprise that more and more patients have begun to ask their physicians about testosterone therapy as another way to get there. The request often comes in the same conversation with questions about Viagra, Cialis and Levitra, used to treat erectile dysfunction.

"Manopause" is real but is usually more gradual and less obvious than female menopause. There is a bona fide role for restrained testosterone replacement for patients who have clinically significant symptoms and very low testosterone levels on lab testing. The goal should not be to make a guy feel like he is 21 when he is 61, and risk factors must be well understood by those seeking treatment and carefully monitored by a trained medical provider.

Testosterone and ethanol may be a high-risk mixture, but testosterone coupled with unrealistic expectations and misinformation also has the potential to lead men, young and old, into the danger zone.

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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.