THESIS STATEMENT
This project aims to discuss the recent rapid increase in the use of testosterone
replacement therapy (TRT) in elderly men in the United States. In addition to covering
background information on testosterone as a natural hormone and as a medical drug,
this paper will focus on the ethics of prescribing testosterone to older, especially
obese, men and the importance of physician counseling during the course of treatment.
INTRODUCTION
Today’s world: constantly bombarded with billboard and television advertisements
regarding low testosterone treatment
Global Industry Analysts, Inc. predicts that the TRT market will reach over five billion
dollars by 2017
 A giant of an industry that is continuing to grow
So why is this industry exponentially growing?
Is there a sudden increase in men with low testosterone in our society or could other
factors be playing a role?
BACKGROUND
Roles of Testosterone:
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maintaining BMD, muscle mass, and strength
decreasing body fat and BMI
increasing mood, energy, cognition, and memory
maintaining libido and sexual function
Testosterone levels naturally decrease as one ages
“Normal” level of total testosterone: ranges from 250-1200 ng/dL
Symptoms are reproducible at a given level
Effect of the degree of change in testosterone levels
Genetic polymorphisms at the androgen receptor protein
Free vs. Bioavailable vs. Total Testosterone Levels
Adverse effects: acne, gynecomastia, erythrocytosis, and edema
 Reversible and not particularly life-threatening
Serious cardiovascular adverse effects?
 No rigorously designed double-blind, placebo-controlled studies yet
DISCUSSION
Physician Counseling: Extremely important, yet unfortunately lacking
Ease and convenience of writing a script for testosterone supplementation rather than
thoroughly considering differential diagnosis
Patients not thoroughly counseled about the risks and side effects
Portion of patients that actually truly need TRT
 injury/loss of the testicles, genetic abnormalities, pituitary gland dysfunction, etc.
Obesity’s effect on the TRT industry
 35% of our population is obese
 Obesity: fatigue/tiredness, low confidence/self-esteem, decreased libido, erectile dysfunction, and
decreased muscle mass
Adipose tissue: aromatase enzyme
CONCLUSION
Multi-billion dollar industry: dependent on obesity?
Patients with recurring complaints: tired, weak, no sex drive…
 annoying and frustrating very quickly for physicians
 many have little self-discipline especially with diet and exercise
What is my ethical responsibility as a future physician?
 Ease of just writing a script vs. thorough diet and exercise counseling
More money and resources into fields like nutrition and exercise education
 Stop temporarily treating the downstream effects of an underlying problem
Better rapport = better relationship with patients = higher likelihood for compliance
 Positive effect of narrative medicine