Page 21 - Journal of Special Operations Medicine - Fall 2015

was in response to three recent studies that showed in- performance enhancement. Rather, it is critical that we
creased risk. The first study was a small trial with 206 take the time to engage in appropriate clinical conversa-
men called the Testosterone in Older Men (TOM) trial tions with our patients regarding their concerns and the
that was published in 2010. The authors stopped the intent of our evaluation and management. Our Special
7
study early because of a 4-fold higher risk of cardiovas- Operators deserve the best from us, and this is one way
cular events in the TRT arm compared with the placebo we can best serve their interests.
arm. The second study was a Veterans’ Administration
retrospective trial published in the Journal of the Ameri- Disclosures
can Medical Association in November 2013 that looked
at men with a TT of less than 300ng/dL who were under- The authors have nothing to disclose.
going angiography. The authors compared the rate of
8
death, myocardial infarction, and stroke during a 3-year References
period between men receiving TRT (n = 1223) versus
those not receiving TRT (n = 7486). They found a 25% 1. Kane S. USASOC/1st SFC(A), Androgen deficiency CPG. Per-
event rate in the TRT arm versus 20% in the control sonal communication, October 20, 2014.
arm. The third study, published in January 2014, was a 2. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone
therapy in men with androgen deficiency syndromes: an En-
retrospective evaluation of a large medical records sys- docrine Society Clinical Practice Guideline. J Clin Endocrinol
tem that found a relative risk of 1.36 of nonfatal myo- Metab. 2010;95:2536–2559.
cardial infarction in men receiving TRT versus those not 3. Dondona P, Rosenberg MT. A practical guide to male hypo-
receiving TRT. These three studies suggest that there gonadism in the primary care setting. Int J Clin Pract. 2010;
9
64:682–696.
is an increased risk of cardiovascular events in patients 4. Basaria S. Male hypogonadism. Lancet. 2014;383:1250–1263.
on TRT, but the average age of those subjects was in 5. Paduch DA, Brannigan RE, Fuchs EF, et al. The laboratory di-
their 60s or 70s. To date, there are very limited data agnosis of testosterone deficiency. Urology. 2014;83:980–988.
regarding the safety of TRT in younger men. Of note, 6. Defense Centers of Excellence Clinical Recommendation.
following the FDA’s warning in January 2014, the Ne- Indications and conditions for neuroendocrine dysfunction
vada State Athletic Commission and the Ultimate Fight- screening post mild traumatic brain injury. August 2012. Re -
trieved from https://dvbic.dcoe.mil/material/indications-and
ing Championship both elected to ban the use of TRT -conditions-neuroendocrine-dysfunction-screening-post
in competition. In contrast, a large (N=117,094) retro- -mtbi-recommendations.
spective review published earlier this year also looked at 7. Basaria S, Coviell AD, Travison TG, et al. Adverse events
patients on TRT and found that those patients on TRT associated with testosterone administration. N Engl J Med.
2010;363:109–122.
has statistically significant lower rates of myocardial in- 8. Vigen R, O’Donnell, CI, Baron AE, et al. Association of tes-
farctions, ischemic stroke, and all-cause mortality. In tosterone therapy with mortality, myocardial infarction, and
10
the absence of data on long-term safety from prospec- stroke in men with low testosterone levels. JAMA. 2013;310:
tive, randomized control trials, weighing the risks and 1829–1836.
benefits of TRT can be difficult. 9. Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk
of non-fatal myocardial infarction following testosterone
therapy prescription in men. PLoS One. 2014;9:1–7.
Conclusion 10. Sharma R, Oni O, Gupta K, et al. Normalization of testos-
terone level is associated with reduced incidence of myocar-
Due to various social pressures, there is no doubt that dial infarction and mortality in men. Eur Heart J. 2015; DOI:
Operators will continue to present to clinics for evalu- 10.1093/eurheartj/ehv346.
ation of possible testosterone deficiency. It is important
for providers to understand the pathophysiology of
testosterone to properly guide men through the evalua-
tion for hypogonadism. Making the diagnosis of Low T MAJ Grumbo, MC, USA is currently a battalion surgeon
with 1st Special Forces Group (Airborne) at Joint Base Lewis-
based off of one testosterone measurement is inappropri- McChord, Tacoma, Washington. He completed his Family
ate. The diagnosis should be unequivocal and requires Medicine training at Fort Bragg, North Carolina. E-mail:
three separate morning measurements of testosterone Robert.Grumbo@soc.mil.
and further physical examination and laboratory investi-
gation to appropriately diagnose and manage the condi- LTC Haight, MC, USA is currently a member of the Sports
tion. The USASOC CPG helps providers with the initial Medicine faculty at the Family Medicine Residency Program
evaluation of Soldiers concerned about their testoster- at Madigan Army Medical Center, Joint Base Lewis-McChord,
one level. Importantly, we as providers should not re- Tacoma, Washington. He previously served at the Group Sur-
flexively dismiss our Operators’ concerns as a desire for geon for 1st Special Forces Group (Airborne).

Evaluation for Testosterone Deficiency 9