From Research To Practical Application
Reviewed by Forest A. Tennant, MD, DrPH
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.
— Jul/Aug 2004
The full article is now available as a PDF and may be
purchased for $5 and downloaded immediately:
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