Ask the Doctors: Testosterone therapy can aid men with osteoporosis

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Q: Are there any benefits to testosterone therapy for older men who have osteoporosis of the spine and hip? I understand that it comes with an increased chance of prostate cancer.

A: These are smart questions to ask. Too many people think that men don't develop osteoporosis, but in fact, low testosterone is a prime risk factor for osteoporosis in men -- and not just in older men. Low bone density has clearly been shown in younger men whose testes produce very low levels of testosterone. For them, testosterone therapy has been shown to increase bone density after one year. For older men, the answers are more complex.

A 1996 study assessed the impact of testosterone therapy in 36 men with a median age of 58 who had testosterone deficiency verified by three different tests at different times. The men were given testosterone injections regularly for up to 18 months. At the end of the study, the testosterone had increased bone density in the spine by 5 percent while also increasing lean muscle mass and decreasing body fat.

A 2017 study looked at the impact in 211 men over the age of 65 (average age of 72) who had two morning testosterone readings below normal (lower than 275 nanograms per deciliter). The men were given the testosterone treatment AndroGel, of which they applied 5 grams daily to the skin for one year; a control group received a placebo gel. Both groups were given additional calcium and vitamin D. The testosterone group showed a 7.5 percent increase in bone density of the spine, while the placebo group showed an increase of only 0.8 percent. Hip bone density increased by 3.3 percent in the testosterone group, and by 2.1 percent in the placebo group.

A 2004 study also looked at men with low testosterone (below 350 ng/dL), with 24 men receiving an injection of 200 milligrams of testosterone every two weeks for three years, and 24 receiving a placebo injection every two weeks. At the end of the study, the testosterone group showed an improvement in spinal bone density by more than 9 percent; the placebo group showed no change. Again, there was only a slight improvement in hip bone density in the testosterone group.

Testosterone therapy clearly benefits men with low testosterone levels, so the natural question is: What about for men with normal levels? Unfortunately, there is no good data to support testosterone use in men with a normal level -- especially considering that testosterone increases both the size of the prostate gland and blood PSA levels. That is, there is a theoretical increased risk of prostate cancer with the use of testosterone. In men with low levels, using testosterone to bring those levels to normal may pose only a slight risk, but still, they should be monitored with PSA tests and prostate exams when on such therapy.

What appears to be more concerning is a slight increase in strokes and heart attacks in men using testosterone therapy. This risk appears to be correlated more strongly with injectable testosterone. And again, for men with lower levels, testosterone therapy may not show this risk.

In short, if your testosterone level is low and if you have a low risk for prostate cancer, you should consider testosterone therapy. Not only will it help build muscle mass, decrease fat, enhance libido and increase energy, it will also help increase your bone density.

Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles. Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.

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