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Low testosterone levels for men can mean high health risks. After
decades of research and hype surrounding female menopause and
hormone replacement therapy, men have recently started receiving some
attention about their own age-related hormonal decline - andropause.
Page 1
Men with low testosterone are at a greater risk. We know that studies show
that men with LOW testosterone have a HIGHER incident of heart disease. Low
testosterone may be a predictive marker for those at high risk of cardiovascular
disease. Endogenous testosterone and mortality due to all causes, cardiovascular
disease, and cancer in men: European prospective investigation into cancer in Norfolk
(EPIC-Norfolk) Prospective Population. Study. Circulation. 2007 Dec 4;116(23):2694701. See all of the studies listed in our 26 page whitepaper on Testosterone.
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things they had not done for years because of increased energy, sex drive, etc. Proper
testing was not done as noted by many experts. Further, most of these men were not only
older with limited mobility when they started the study, but had chronic pre-existing
conditions.
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Less bone, more fat. While osteoporosis hasnt always been considered a disease that
afflicts males, the rising incidence of bone mass degeneration among aging men points a
finger to some age-related cause. As androgen receptors are expressed in osteoblasts
(bone-forming cells) researchers now believe that androgens have some direct effect on
bone formation and resorption.
Declining Testosterone, Fat Mass and Heart Risk. A growing body of research
now suggests that an age-related increase in fat mass, or obesity, can be attributed to a fall
in free testosterone and growth hormone levels. Moreover, studies report a connection
between abdominal obesity and increased cardiovascular mortality and Type II diabetes
mellitus. Recent findings from the University Hospital in Ghent, Belgium illustrate that
age is related to a drop in free testosterone levels and free insulin-like growth factor-1,
while contributing to an increase in body mass index and fat mass.
The Heart: Also note that testosterone concentrations are inversely related to
mortality due to cardiovascular disease and all causes. Low testosterone may be a
predictive marker for those at high risk of cardiovascular disease. Khaw KT, Dowsett M,
Folkerd E, et al. Endogenous testosterone and mortality due to all causes, cardiovascular
disease, and cancer in men: European prospective investigation into cancer in Norfolk
(EPIC-Norfolk) Prospective Population. Study. Circulation. 2007 Dec 4;116(23):2694701.
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brachial artery reactivity in men with coronary artery disease. Am J Cardiol 2000
Jan 15;85(2):269-72.
Intracoronary injection of T at men with established CAD
Coronary artery dilation
Increased coronary blood flow
Webb CM et al. Effects of testosterone on coronary vasomotor regulation in men with
coronary heart disease. Circulation 1999 Oct 19;100(16):1690-6.
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One recent study consisting of 372 males aged >20-85, revealed that body mass index
and age were independent factors in determining testosterone levels. These decreased
by about one quarter when researchers compared the young controls to men in the elderly
group, while free testosterone levels fell by almost half with age. Likewise, fat-free
mass decreased by 18.9%. In a subgroup of 57 men aged 70-80 years, the lower that
testosterone levels dropped, the higher the percentage of body and abdominal fat, as well
as plasma insulin levels.
Low Testosterone and Increased Risk of Diabetes and Adipose Fat. Other
findings indicate that low testosterone levels predisposed men to adipose fat which, in
turn, seemed to raise their risk of diabetes mellitus. Researchers at the University of
Washingtons Department of Medicine set out to examine the effects of age-related
decreasing serum testosterone levels on intra-abdominal fat in a group of 110 secondgeneration healthy Japanese-American men. Measurements were taken first to establish
baseline levels of glucose, body mass index, visceral adiposity, subcutaneous fat, fasting
insulin and C-peptide levels, and overall testosterone levels (which were within the
normal range relative to the mens age).
When the researchers performed follow-up measurements 7.5 years later, their results
indicated that intra-abdominal fat had increased by an average of 8.0 centimeters squared.
More importantly, though, they found that the change in intra-abdominal fat correlated to
Truth About Testosterone
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baseline total testosterone levels, but they were not significantly related to other
measurements such as body mass index, total fat or subcutaneous fat. The study authors
concluded that, in their sample, lower baseline total testosterone independently
predicts an increase in intra-abdominal fat. This would suggest that by predisposing to
an increase in visceral adiposity, low levels of testosterone may increase the risk of type
II diabetes mellitus.
Note: Diabetic patients are at a high risk of heart disease and generally
die of heart disease.
Low testosterone Levels, Excess Abdominal Fat and Heart Disease.
Similarly, another study that analyzed some of the health effects of excess abdominal fat,
also referred to as android obesity, reported that individuals exhibiting upper body excess
fat distribution tend to have lower levels of plasma testosterone and growth hormone
levels, suggesting what the authors describe as complex hormonal abnormalities.
Abdominal obesity lends itself to an apple-shaped figure and has been related to a
heightened risk of conditions such as cancer, diabetes and heart disease. These
researchers believe that, Visceral fat tissue, through its portal drainage, could be an
important source for free fatty acids that may exert complex metabolic effects:
involvement in hepatic lipogenesis, increase in hepatic neoglucogenic flux, reduction in
insulin metabolic clearance and involvement in peripheral insulin resistance through a
competition mechanism described by Randle.
They conclude that abdominal obesity may be related to diabetes by means of an
enhanced fatty acid made available from fat tissues (visceral and subcutaneous) in
individuals who are genetically predisposed to type II diabetes. Research has also pointed
to the possibility of a link between abdominal obesity and hypercorticism, or elevated
cortisol levels. A reason for this, suggest scientists, might be that excess cortisol opposes
testosterone and growth hormone production, both of which are regulators of body fat.
Moreover, low testosterone levels also seem to encourage cortisol levels to rise and elicit
their many aging effects, including immune dysfunction, brain cell injury, arterial wall
damage and other assaults.
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testosterone levels among patients with coronary heart disease were significantly
about 40%lower than in healthy subjects. Moreover, there was a negative
association between plasma testosterone levels and plasma triglyceride levels and
lipoprotein (a), which translated into higher blood lipid levels relative to lower
testosterone levels. Contrarily, a positive association between plasma testosterone
levels and high-density lipoprotein cholesterol and high-density lipoprotein 3
cholesterol meant that higher testosterone levels equaled higher good cholesterol
levels.
The Natural Aging Factor. It is well documented in research that sex hormones
such as testosterone are vital components in the sexual development of pubescent males,
as well as contributing to the increase of their muscle and bone mass as they transform
from boys into men. Meanwhile, dwindling testosterone levels as a result of metabolic
aging trigger the opposite kind of effects, including the loss of body hair and progression
of male pattern baldness, loss of muscle and bone mass, and increased fat.
Low testosterone levels arent just the prospect of a small segment of the male population
but rather, they tend to affect the male population as a whole. Natural aging causes a
gradual decline in male hormones, so that by age 70, men have less than a quarter of their
optimal testosterone levels. Some figures reveal that free testosterone levels start to fall at
the age of 25. At NBH Lifetime Health, we have treated many men in their 30s and even
several in their 20s.
While men with normal testosterone levels sometimes exhibit some of the symptoms,
which may very well stem from other causes besides hypogonadism, the fact that
androgen therapy usually alleviates these symptoms suggests a hormonal deficiency as
the root cause of such deterioration in health.
Many study results show a positive role in maintaining adequate testosterone levels
in aging males. In terms of overall body composition, for example, research has
demonstrated a measurable increase in lean body mass and in mid-arm
circumference and the decrease in waist-to-hip ratio in elderly men, after they
received androgen replacement therapy to treat their low testosterone levels.
Page 8
As one researcher noted: The adverse effects of low testosterone levels are apparent,
bothersome, and serious enough to warrant further examination of how androgen impacts
on various aspects of male health, and how androgen replacement therapy can serve as a
means to contain age-related hormonal pitfalls.
The biggest challenge may conceivably be to restore the reputation of testosterone, which
has been cast as a bad steroid for some time. Another task for research will be to
continue building a case for the vital role that androgens have with regard to bone, heart,
sexual, mental health and general well being. Offering solid proof of testosterones
various functions will help to show that, while testosterone therapy may not be
appropriate for every man, it would be a shame for other men to miss out on its merits.
Page 9
published in by a Mayo Clinic Journal. Morley, JE. Testosterone replacement and the
physiologic aspects of aging in men. Mayo Clin Proc. 2000 Jan; 75 Suppl:S83-7.
Studies show that men with LOW levels of testosterone are more likely to get prostate
cancer. There have been 50 year of studies and none have shown a connection between
testosterone levels and prostate cancer growth. A 2006 study from Harvard Medical
School concluded: there is not now, nor has there ever been a scientific basis for the
belief that testosterone causes prostate cancer to grow.
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Estrogen: The belief that estrogen, rather than testosterone, is one of the prime
hormonal initiators of prostate cancer is based on the fact that while testosterone levels
are highest in young men, prostate cancer essentially is never seen in this population. It is
only in older men, who have lower levels of testosterone but higher levels of estrogen and
its breakdown products, that prostate cancer is a significant health threat. However,
young men do have high levels of estradiol so this belief is questionable at best.
Further, high doses of estrogen have been used to treat cancer of the prostate and the
GnRh agonist, Lupron, is used to decrease the levels of testosterone as a chemotherapy
treatment. However, Lupron would also decrease estrogen. Many men have been treated
successfully in the past with DES, diethylstilbestrol, and it controlled prostate
cancer. Men can get significant breast enlargement with DES. Estrogen treatment is again
being used to treat prostate cancer.
Conventional Studies: The Institute of Medicine report includes some data showing
that optimal levels of testosterone do not cause prostate cancer, and in fact may protect
against this major killer of elderly men. No study has shown that testosterone causes
prostate cancer and we have not had a single male develop prostate cancer on our
program.
Population-based studies clearly document the relationship between aging and both
increases in prostate cancer incidence rates and decreases in circulating [and free]
testosterone levels. While this relationship does not equal causality, the findings do raise
Truth About Testosterone
Page 11
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Numerous studies have supported the concept that testosterone has a neuroprotective
effect on cognitive and brain function. In rat models, testosterone has been shown to
decrease -amyloid secretion from rat cortical neurons and reduce -amyloid induced
neurotoxicity in cultured hippocampal neurons. In humans, testosterone suppression for
management of prostate cancer resulted in a two-fold increase in plasma -amyloid
concentrations in elderly men, suggesting that endogenous testosterone might reduce
plasma amyloid concentrations in humans.
Results of the current study suggest that in aging men, maintenance of free
testosterone concentrations in the higher part of the normal range may decrease the
risk of developing Alzheimer's Disease.
Testosterone is of course a major heart factor in that low levels are associated with heart
disease. At NBH Lifetime Health, we have found that most men over 40 have less than
optimal levels of free testosterone. More and more, we are finding the younger males can
also have these difficulties. Heart disease is still the No.1 killer of men (and women).
Page 13
A study conducted at Harvard University concluded that essentially all type II diabetic
males had low levels of testosterone. This is not surprising to us as we have been treating
overweight males for years and testing their free and total testosterone levels.
Conclusion: Protect your mind, your heart and your weight with Testosterone.
References: Credit for the Alzheimers section research to Labrix Labs.
Alzheimer's Disease Fact Sheet. U.S. National Institutes of Health National Institute in
Aging. http://www.nia.nih.gov/Alzheimers/Publications/adfact.htm.Accessed 1/3/2011.
Gandy S, et al. Chemical andropause and amyloid-beta peptide. JAMA
2001;285:2195-2196.
Gouras, G.K. et al. Testosterone reduces neuronal secretion of Alzheimer's betaamyloid peptides. Proc Natl Acad Sci USA 2000; 97:1202-1205.
Moffat, S.D. et al. Free testosterone and risk for Alzheimer disease in older men.
Neurology 2004; 62:188-193. Asian J Androl. 2012 May; 14(3): 428435.
Low Testosterone Levels and Increased Risk of Heart Disease. Men with coronary
heart disease had a significantly lower total testosterone, free testosterone, and
bioavailable testosterone. 3
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So why did the two recent studies show that there was an increased risk of
developing heart disease in male patients that were prescribed testosterone
replacement therapy?
There are five serious flows associated with the two recent trials. [THERE ARE 6 IN
THAT THE VA STUDY, WHEN PROPERLY CALCULATED, SHOWED A
DECREASE RISK OF HEART ATTACKS AND STROKE. IT SEEMS THAT
ONLY NATURAL BIO HEALTH AND ONE HARVARD COLLEGE PROFESSOR
CALCULATED CORRECTLY.]
Firstly, estrone and estradiol levels were not measure in the subjects in the studies. High
estrogen levels in males have been found to be associated with an increase risk in the
development of heart disease and stroke. [It is the ratio more than the absolute value].
Estrogen levels may elevate due to an increase in aromatase activity, alteration in liver
function, zinc deficiency, obesity, abuse of alcohol, drug induced estrogen imbalance, and
ingestion of estrogen-containing foods or environmental estrogens.
Truth About Testosterone
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High Estrogens are Associated with an Increased Risk of Heart Disease and Stroke
Study showed that high estradiol in males was associated with an increased risk of stroke.
38. Study showed that elevated circulating estradiol is a predictor of progression of
carotid artery intima media thickness in middle age men. 39 High estradiol levels in men
were associated with acute myocardial infarctions. 40 High estrone and low testosterone
levels were associated with promoting the development of atherogenic lipid milieu in
men with coronary heart disease. 41
Low testosterone and elevated estradiol was associated in this study with lower
extremity peripheral arterand low testosterone levey disease in older men. 42 Men with
myocardial infarction had high estradiol ls. 43 Elevated levels of estradiol in men were
associated with an increase incidence of strokes, peripheral vascular disease, and carotid
artery stenosis compared to subjects with lower estradiol levels. 44 Elevated levels of
estrogen in men are associated with an increased risk of heart disease. 45
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enhance early atherosclerosis. 50 The conclusion of the author of this trial was that the
findings highlighted a new androgen receptor/nuclear factor-kappaB mediated
mechanism for vascular cell adhesion molecule-1 expression and monocyte adhesion
operating in male endothelial cells that may represent an important unrecognized
mechanism for the male predisposition to atherosclerosis.
The higher the dose of testosterone that is prescribed the more it is converted by 5 alphareductase into DHT. In these two recent trials that suggest that testosterone replacement
increases the risk of heart disease in men, DHT levels were not measured.
Conclusion. Given the plethora of medical studies indicating the beneficial effects of
properly prescribed testosterone, one would have to conclude that these two recent
medical trials are poorly their conclusion is flawed. Some of the patients did not have
repeat testosterone levels measured. Consequently, the patients may have had
supraphysiological levels of testosterone. In addition DHT, estrone, estradiol, and HCT
levels were not addressed.
Furthermore, the medical literature has shown that hormones in the body are a symphony
and This web of interconnection was not considered.
References
1. Vigen, R., et al., Association of testosterone therapy with mortality, myocardial
infarction, and stroke in men with low testosterone levels, JAMA 2013; 310(17):182936.
2. Finkle, W., et al., Increased risk of non-fatal myocardial infarction following
testosterone therapy prescription in men, PLOS January 29, 2014.
3. English, K., et al., Men with coronary artery disease have lower levels of androgens
than men with normal coronary angiograms, Eur Heart Jour 2000; 21(11):890-4.
4. Vermeulen, A., Androgen replacement therapy in the aging male---a critical
evaluation, Jour Clin Endocrinol Metabol 2001; 86:2380-90.
5. Malkin, C., et al., Low serum testosterone and increased mortality in men with
coronary heart disease, Heart 2010; 96:1821-25.
6. Ma, R., et al., Erectile dysfunction predicts coronary heart disease in type 2 diabetes,
Jour Amer Coll Cardiol 2008; 51:2045-50.
7. Turhan, S., et al., The association between androgen levels and premature coronary
artery disease in men, Coron Artery Dis 2007; 18(3):159-62.
8. Bhasin, S., et al., Serum free testosterone is inversely related to carotid intima-media
thickness (IMT) and plaque score, Diabetes Care 2003; 26:1869-73.
9. Svartberg, J., et al., Low testosterone levels are associated with carotid atherosclerosis
in men, Jour Int Med 2006; 269(6):576-82.
10. Ding, E., et al., Sex differences of endogenous sex hormones and risk of type 2
diabetes: a systematic review and meta-analysis, JAMA 2006; 295:1288-99.
11. Laaksonen, D., et al., Testosterone and sex hormone-binding globulin predict the
metabolic syndrome and diabetes in middle-age men, Diabetes Care 2004; 27:1036-41.
12. Pasquali, R., et al., Effects of acute hyperinsulinemia on testosterone serum
concentrations in adult obese and normal-weight men, Metabolism 1997; 46(5):526-9.
13. Rizza, R., et al., Androgen effect on insulin action and glucose metabolism, Mayo Clin
Proc 2000; 75(Suppl):S61-S64.
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14. Stellato, R., et al., Testosterone, sex hormone-binding globulin, and the development of
type 2 diabetes in middle-aged men: prospective results from the Massachusetts male
aging study, Diabetes Care 2000; 23(4):490-94. Rizza, R., et al., Androgen effect on
insulin action and glucose metabolism, Mayo Clin Proc 2000; 75(Suppl):S61-S64.
15. Dardona, P., et al., Update: hypogonadotropic hypogonadism in type 2 diabetes and
obesity, Jour Clin Endo and Met 2011; 96(9):2643.
16. Hyde, Z., et al., Low free testosterone predicts mortality from CVD but not other
causes: The Health in Men Study, Jour of Clin Endocriol and Met 2012; 97(1):179.
17. Haring, R., et al., Low serum testosterone levels are associated with increased risk of
mortality in a population-based cohort of men aged 20-79, European Heart Jour 2010;
31(12):1494-1501.
18. Araujo, A., et al., Endogenous testosterone and mortality in men: a systematic review
and meta-analysis, Jour Clin Endocrinol Metab 2011; 90:3007-19.
19. Torkler, S., et al., Inverse association between total testosterone concentrations,
incident hypertension and blood pressure, Aging Male 2011; 14(3):176-82.
20. Guder, G., et al., Low circulating androgens and mortality risk in heart failure, Heart
2010; 96:504-09.
21. Jankowska, E., et al., Anabolic deficiency in men with chronic heart failure: prevalence
and detrimental impact on survival, Circulation 2006; 114:1829-37.
22. Khaw, K., et al., Endogenous testosterone and mortality due to all causes,
cardiovascular disease, and cancer in men: European Prospective Investigation into
Cancer in Norfolk (EPIC-Norfolk) Prospective Population study, Circulation 2007;
December 4th.
23. Baum, N., et al., Testosterone replacement in elderly men, Geriatrics 207; 62:15-8.
24. Marin, P., et al., Androgen treatment of abdominally obese men, Obes Res 1993;
1:245-48.
25. Rosano, G., et al., Acute anti-ischemic effect of testosterone in men with coronary
artery disease, Circulation 1999; 99:166-70.
26. Webb, C., et al., Effects of testosterone on coronary vasomotor regulation in men with
coronary heart disease, Circulation 1999 100(16):1690-96.
27. English, K., et al., Low dose transdermal testosterone therapy improves angina
threshold in men with chronic stable angina, Circulation 2000; 102:1906-11.
28. Haffner, J., et al., Sex hormones and DHEASO4 in relation to ischemic heart disease in
diabetic subjects, The WESDR Study. Diabetes Care 1996; 19:1045-50.
29. Channer, K., et al., Cardiovascular effects of testosterone: implications of the male
menopause? Heart 2003; 89(2):121-22.
30. Whitsel, E., et al., Intramuscular testosterone esters and plasma lipids in hypogonadal
men: a meta-analysis, Amer Jour Med 2001; 111:261-69.
31. English, K., et al., Low-dose transdermal testosterone therapy improves angina
threshold in men with chronic stable angina: A randomized, double-blind, placebocontrolled
study, Circulation 2000; 102(16):1906-11.
32. English, K., et al., Testosterone acts as a coronary vasodilator by a calcium antagonistic
action, Jour Endocrinol Invest 2002; 25(5):455-58.
33. Corona, G., et al., Hypogonadism as a risk factor for CV mortality in men: a metaanalytic
study, Eur Jour Endocrinol 2011; 165:687-701.
34. Malkin, C., et al., The effect of testosterone replacement on endogenous inflammatory
cytokines and lipid profiles in hypogonadal men, Jour Clin Endocrinol Metab 2004;
89(7):3313-18.
35. Carminiti, G., et al., Effect of long-acting testosterone treatment on functional exercise
capacity, skeletal muscle performance, insulin resistance, and baroreflex sensitivity in
elderly patients with chronic heart failure a double-blind, placebo-controlled,
Page 19
More studies
Published online 2012 April 23. doi: 10.1038/aja.2012.21
PMCID: PMC3720171
Testosterone and cardiovascular disease in men
Paul D Morris and Kevin S Channer
Irrespective of regional variations in the prevalence of coronary heart disease, the
burden of coronary disease in men is approximately three times that of women.1
Moreover, men develop coronary disease approximately 10 years ahead of women.
Truth About Testosterone
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Multiple logistic regression analyses have shown that these differences are not explained
by simple differences in coronary risk factor profiles. 2 The relationship between male
gender and the prevalence of coronary heart disease suggests a role for sex hormones in
the aetiology of cardiovascular disease.
Historically, much attention has been paid to the cardioprotective effects of female sex
hormones in women. In women, physiological levels of oestrogen appear protective
against atherosclerosis, whereas conditions associated with oestrogen deficiency such as
early menopause or bilateral oopherectomy are associated with an increased burden of
coronary disease.3, 4, 5
The combination of: (i) the male preponderance of coronary disease; (ii) the
cardioprotective effects of oestrogens in pre-menopausal women; and (iii) the increased
cardiovascular death in men abusing anabolic steroids, have led to the view that
testosterone is deleterious to the male heart. Contrary to this view, current evidence
suggests that normal and physiological levels of testosterone are not deleterious to
the male heart and are, in fact, beneficial.
It is hypotestosteronaemia (low testosterone) which is associated with adverse coronary
risk profiles and with coronary morbidity and mortality in men. Moreover, androgen
replacement therapy has positive effects on coronary risk factor profile and acts as a
vasodilator demonstrating potential, because it is an anti-ischaemic agent.
Page 21
Clinical signs can include fine-wrinkled dry skin, low hairline, gynaecomastia and
muscle wasting. Due to the non-specific nature of the symptoms, hypogonadism often
remains undiagnosed and thus untreated in many cases. In others, it is diagnosed but
remains untreated due to a perceived concern regarding adverse iatrogenic effects on the
prostate and heart. Harman et al.25 investigated the nature and potential aetiological
factors involved in the change in sex hormone levels with age in the Baltimore
Longitudinal Study of Aging. They found that in 890 generally healthy men, both
total and free testosterone decreased at a constant rate from the third to ninth
decade. the fall in free testosterone was more impressive and due, at least in part, to
the significant rise of sex hormone binding globulin with age. These observations were
independent of obesity, comorbid illnesses, medication, smoking and alcohol
consumption.
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risk factor profile with improvements in glycaemic control, adiposity and lipid
profiles.45
. In a study of over seventy thousand men (73 196) treated with androgen
suppressive therapy (blocking testosterone) for prostate cancer, there was a 44%
increase in the risk of developing diabetes and 16% increase in the risk of
cardiovascular death or myocardial infarction, effects which were evident as early
as 14 months.13 Similar conclusions were drawn in a study of men treated by
orchidectomy, where, over a 10 year period, there was a twofold increase of
cardiovascular mortality.50 Androgen suppressive therapy has also been linked with
increased central blood pressure, insulin resistance, and hyperglycaemia. 51, 52, 53, 54
However, one must be careful to consider the difference in androgen levels between
the moderate hypotestosteronaemia associated with aging and the more extreme low
testosterone levels associated with androgen suppressive therapy used in prostate cancer
treatment.
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They looked at 850 men over a 4- to 8-year period controlling for comorbid conditions
which would affect mortality, e.g. concurrent cancer. They found that men with low
testosterone levels had an 88% (20.1% vs. 34.9%, P<0.001) relative increase in allcause mortality risk when compared with those with normal testosterone levels at
baseline.
In 2007, the InCHIANTI study demonstrated that an age-associated fall in
bioavailable testosterone was associated with increased risk of death.70 In a 6-year
follow-up study of 410 men aged over 65 years, they found that this effect was made
more pronounced and more statistically significant when low testosterone was associated
with similar decline in insulin-like growth factor and dehydroepiandrosterone sulphate.
In contrast to men with all three hormones above the lowest quartiles, men with one,
two or three hormones in the lowest quartiles were increasingly at more risk of
death.
In the largest study to date investigating the effects of endogenous testosterone levels and
mortality, the European Prospective Investigation into Cancer Norfolk study 72
prospectively investigated all-cause and cardiovascular mortality in 11 606 healthy men
between the ages 40 and 79 years at baseline. Over a 6- to 10-year follow-up period,
they observed a statistically significant association between baseline serum
testosterone level and all-cause (HR: 0.75; 95% CI: 0.551.00), cardiovascular (HR:
0.62; 95% CI: 0.450.84) and cancer related (HR: 0.59; 95% CI: 0.420.85) deaths
(P<0.001) for each association after controlling for comorbid conditions and
behaviours.
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