Dear Dr. Roach: I am a 62-year-old male who gets weekly testosterone injections. My semiannual blood work comes back fine. I have no side effects except that I lose my temper with people easier now. I have a little more energy and sex drive. My doctor believes that since he has me on Arimidex to keep my estrogen level low, testosterone is not harmful to me. I wanted another opinion, since all I hear now is that testosterone supplements can cause increased risk of heart attack and stroke. Does the Arimidex make testosterone safer?
Dear J.H.: Testosterone replacement treatment for men should be given only to men with consistently low testosterone levels and who have symptoms. The most common early symptoms in adult men are low energy levels, poor libido and depressed mood. Later, other symptoms and signs, such as low muscle mass, anemia and osteoporosis, may occur. None of these is specific for low testosterone levels, so it takes some judgment to begin treatment. Testosterone isn’t appropriate for healthy men who have a single borderline or low testosterone level without significant symptoms.
The role of estrogen in adult men is complex and incompletely understood. Low estrogen seems to predispose people to increasing body fat. Anastrozole (Arimidex) is an aromatase inhibitor, and since aromatase is the enzyme that makes estrogen, anastrozole lowers estrogen levels, which is why it is indicated in women with estrogen-sensitive breast cancers. In men, a trial of anastrozole without testosterone showed increased testosterone levels but no improvements in muscle strength or mass. With combined testosterone and anastrozole treatment, triglyceride levels decrease (which may be why your doctor is recommending combination treatment), and testosterone levels are higher than with testosterone alone. However, I could find no good evidence that anastrozole improves effectiveness of testosterone treatment, nor any direct evidence that it is any safer than testosterone alone.
The risks of testosterone treatment appear to be modest. There is a theoretical increased risk of prostate cancer, so frequent screening should be carefully considered. Blood clot risk may be increased, and there is mixed data regarding heart disease risk.
I recommend that you think twice before beginning testosterone treatment, and I do not recommend anastrozole. As more studies come out, I will revisit my recommendations.
Dear Dr. Roach: I have had nail fungus since 1985 in my toenails and my fingernails. I was treated with oral Lamisil, but it did nothing for my big toe. The problem has continued progressively over the years. I am 80 years old, and it’s still there.
Dear C.J.R.: Are you sure you really want the condition treated? The treatments have potential for real harm, even though it isn’t likely. If the issue is strictly cosmetic, I wouldn’t recommend treatment. If it’s for pain or because you have had skin or soft tissue infections in the area, then treatment is reasonable.
If you pursue treatment, get a culture done to be sure you know what you are treating. Sometimes what looks like a nail infection is really something else (psoriasis, eczema, lichen planus or others). Depending on what the culture shows, you might benefit from itraconazole, an oral antifungal agent.
Email questions to ToYourGoodHealth@med.cornell.edu.