The treatment of low testosterone levels is still a delicate issue in France, despite the proven benefits of replacement therapy, due to underdiagnosis, reticent doctors, and patient prejudices. Eric Huygue, MD, PhD, a urologist at the University Hospital of Toulouse in France, stated at the 117th Annual Conference of the French Urological Association (AFU) that only about 20% of patients with symptomatically low testosterone levels are treated for the deficiency.
According to Huygue, „The treatment of low testosterone levels is effective and safe. It improves the quality of life and overall health of a patient.“ Huygue also highlighted that it particularly impacts fatigue, mood, and libido and was involved in the development of the first French guidelines for the treatment of low testosterone levels in 2021. He urged the need to continue communication efforts to raise awareness among patients and doctors about the benefits of supplementation.
Symptomatic testosterone deficiency primarily affects men over the age of 40. A varied decline in androgen levels can lead to sexual problems, such as erectile dysfunction and low libido, physical symptoms like fatigue, hot flashes, loss of muscle mass, and osteoporosis, as well as psychological disturbances like anxiety, irritability, and depression. In France, there are approximately 340,000 men with symptomatic testosterone deficiency, but only 70,000 of them receive replacement therapy, which accounts for only 20% of those affected. Huygue attributed this low treatment rate to underdiagnosis and the reluctance of physicians and patients.
While routine screening for low testosterone levels in the general population is not recommended, certain individuals are particularly vulnerable, including those with metabolic disorders associated with insulin resistance (such as obesity and type 2 diabetes), cardiovascular diseases, chronic conditions (COPD, cancer, and depression), and those taking specific medications.
According to the French recommendations for the treatment of low testosterone levels, the diagnosis should be based on free or bioavailable testosterone, tested twice a month apart in the morning hours and during fasting. The reference range is determined based on the lower threshold measured by the lab for young men.
Current practices related to the reference range based on the age group of the patient contribute to underdiagnosis of low testosterone levels, Huygue noted. Retrospective studies have also confirmed the safety of testosterone replacement therapy in men who have undergone radical prostatectomy, radiation therapy, or active surveillance. The only contraindications to prescribing testosterone are hematocrit levels over 54%, current breast or prostate cancer, a cardiovascular event less than 3-6 months ago, and attempting to become pregnant.
Additionally, concerns about the cardiovascular health risks of testosterone therapy have been addressed in various international studies. The European Society of Cardiology highlighted the benefits of testosterone and advocated for replacement therapy to prevent cardiovascular risks. The final obstacle in the way of prescribing testosterone replacement therapy is patient perception, which often includes misconceptions about the treatment.
Lastly, there have been reported supply chain disruptions for Androtardyl, the only injectable form that can be reimbursed by the French social security systems, further complicating the prescription and use of testosterone replacement therapy. Testosterone replacement therapies are available in various formulations, including transdermal gels such as Androgel and Fortigel and injections like Androtardyl and Nebido. Oral testosterone undecanoate such as Pantestone is no longer marketed.