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From Research To Practical Application: Long Term Testosterone Treatment

Editor’s note: From time to time, members of the Practical Pain Management Advisory Board may become aware of clinical research that is ground-breaking and has practical application for a broad range of physicians who treat pain. This is the first in an occasional series and reviews a recent study entitled “Long Term Testosterone Gel Treatment Maintains Beneficial Effects on Sexual Function and Mood, Lean and Fat Mass, and Bone Density of Hypogonadal Men” that was published in the May 2004 issue of The Journal of Clinical Endocrinology and Metabolism.

This nation-wide collaborative study analyzed the effects of testosterone gel on 163 hypogonadal men for 36 months. Ages ranged from 19 to 68 years and hypogonadism was determined by a single morning total serum testosterone concentration that was below 300mg/dl (10.4m mal/liter). Physiologic assessments were periodically done for 36 months. Total serum testosterone normalized and sexual function greatly improved. Lean body mass, mood, muscle strength and bone density in the spine and hips all increased over the 36 months: fat mass decreased. All of these physiological improvements have great relevance to pain practitioners since muscle wasting, decreased strength and osteopenia/osteoporous are part and parcel of severe chronic pain states. Unfortunately, pain, per se, produces immobility, anorexia, and depression changes in catecholamine and glucocorticoid metabolism. When coupled with the hypogonadal effects of opioids, particularly those given by intrathical route, the entrapped pain patient will routinely develop a hypogonadal state that is associated with muscle and bone wasting.

This study provides a practical approach for the busy pain practitioner: simply screen for total serum testosterone with a morning blood specimen. If it is below 300ng/ml, initiate daily testosterone gel. Pain practitioners would be well advised to seek an endocrine or internal medicine consultant to help follow the case since the endocrine effects of severe chronic pain are profound.

This study also reveals few side effects and no serious proven complications among the 163 subjects. There was mild skin irritation in 12 subjects and, as expected, slight increases in hematocrit and hemoglobin that are decreased in hypogonadal states. Although three patients, with elevated prostate-specific-antigen, were found by biopsy to have prostate cancer, it is unknown if there was any cause and effect of testosterone gel considering that it occurred in only three of 163 men (mostly in the older group). This detection rate is not above the expected, natural prevalence of prostate cancer in the general population.

Not discussed in this study are the potential therapeutic effects of testosterone gel in halting deterioration of gums and teeth. Dental deterioration is a significant problem in severe chronic pain and while the causes and treatment are uncertain, decalcification of bone is often associated with decalcification of teeth.

This clinical study clearly shows that anabolic stimulation of tissue growth by hormone replacement is positive and possible, and the pain management field can benefit from further investigation in this area.

Last updated on: May 16, 2011
First published on: July 1, 2004