The use of hormonal therapy in "andropause": the pro side.

“An error is the more dangerous the more truth it contains. ” — Henri-Frederic Amiel Although the discovery and synthesis of testosterone and other androgens took place more than 80 years ago, the controversy over their significance, applications and use is no less intense today than it was then. The introduction of injectable forms of testosterone in the first half of the 20th century created great expectations and a rush to treat all sorts of disparate conditions unrelated to a deficiency in testosterone production. The false hopes and misunderstandings due to androgen use and abuse in the absence of hypogonadism resulted in frustration and disappointment for all concerned and seriously interfered with proper scientific evaluation of gonadal steroids, the causes and consequences of their deficiency as well as their treatment. The rumbles from that distant “big bang” still resonate today. And, probably no syndrome experiences the influx of “expert” views from all sorts of walks of life: from endocrinologists and psychiatrists to urological surgeons and gerontologists, from the lay press to the regulatory agencies and from the pharmaceutical to the entertainment industries. The dismal result of all this free-for-all cacophony of opinions is a great deal of confusion, erroneous information and significant detriment to patients and physicians alike.1 Both my opponent and I are believers in the concept of testosterone deficiency syndrome (TDS) and prescribers of testosterone therapy. We may argue about issues of limited consequence such as taxonomy and semantics, but on the fundamental ones (e.g., clinical relevance of the syndrome, its assessment and monitoring therapy), I wish to reiterate that a “con” position is defensible only when TDS is diagnosed and managed incompetently. The absurd view that TDS is an invention of industry blatantly and conveniently ignores medical observations and reports going back 500 years and accelerating since the mid 20th century. It does not merit further discussion. Medical progress brings honest disagreements and evolving opinions. The controversy about TDS spans the whole spectrum, from diagnosis to treatment. Two areas are particularly unsettled: the biochemical diagnosis and the effect of testosterone on prostate health. Two other subjects are relatively new but gaining relevance and importance: the contribution of TDS to the development of the metabolic syndrome and erectile dysfunction and their treatment. But heavily debated issues also include the contribution of diagnostic questionnaires, the most effective delivery forms for testosterone, the long-term efficacy and safety of current preparations, standards for monitoring men receiving exogenous testosterone and, most unfortunately, the unwarranted extrapolation of the results of the Women's Health Initiative (WHI) to the use of testosterone treatment in adult men. Although much has been learned over the last 6 decades about the manifestations of TDS, the efficacy of testosterone treatment and its potential adverse outcomes, most studies have been relatively short or insufficiently powered to reach definitive conclusions. Volumes could be written just to address the issues listed above. Allow me to tackle some of the more relevant ones.