Testosterone’s Overlooked Role in the Treatment of Diabetes in MenJuly 2007
By Edward M. Lichten, MD
For most of my 60 years, I’ve dreamed of finding a medical treatment or cure that could improve humankind. It has been my mission and lifetime quest.
Fifteen years ago, I rediscovered the reparative properties of bioidentical testosterone. It not only reversed my slide into old age, but also reversed my male patients’ diabetes. A hospital-supervised study soon followed, showing that testosterone replacement for men with diabetes was more important than oral diabetic medications, and for some, more important than insulin.
What I could not imagine then was that almost every diabetes specialist, my affiliated national hospital chain, and the state-supervised health insurance carrier would brand me an “enemy of the state” and move to destroy my medical practice and credibility. The American Medical Association provided no support.
This is the story of the inexpensive hormone that can displace up to $20 billion in direct pharmaceutical sales yearly—if only the truth becomes known.
In the First World War, an unsubstantiated report alleged that a dead soldier’s testicles were transplanted into the abdominal wall of a man with gangrene. The story goes that the man recovered and did not require amputation. This story might have been considered whimsical, were it not for the work of the Danish physician Jens Moller, MD, between 1950 and 1984.1 Dr. Moller and approximately 250 other European doctors used injections of bioidentical testosterone to treat diabetes, gangrene, and related heart disease in more than 10,000 male and female patients. Dr. Moller’s enthusiasm overshadowed the observation that the high testosterone dosages used increased the incidence of heart disease in the women who were treated. This led to his public humiliation, a disbanding of the European physicians, and a misconception that testosterone is dangerous.
When I turned 45, I “crashed” seemingly overnight, transformed from an enthusiastic, hard-working, physically potent man to a depressed, lethargic, and exhausted old man. My symptoms included night sweats so extreme that I had to take two showers every night. My colleagues had no idea what to do; one offered to admit me to the hospital to seek an answer. As a physician, however, I knew the hospital offered no answers.
I discovered the cause of this malaise from observations made by older patients in my gynecology practice. Two women told me that their 70-year-old husbands had the same symptoms. This compelled me to conduct “menopausal” laboratory tests on my own blood. The fortunate result is that I was one of the first men to be recognized as “andropausal” (experiencing symptoms of “male menopause”). With this newfound information, I asked my urologist about testosterone replacement. He told me that no one believed in testosterone for men, it was too dangerous, and that the laboratory tests were best explained by the many menopausal women I was treating in my practice—in other words, they had influenced my lab test results!
I searched the literature, found a doctor who believed in testosterone replacement, and began testosterone replacement therapy in 1995. My life has never been sweeter since I began “drinking from my own bioidentical fountain of youth.”
Pictures on my website testify to the dramatic changes in my physical appearance. At 42, I appear tired and wrinkled. At 52, I look muscular and lean, with a renewed enthusiasm radiating from my body and face. My female patients noticed the difference and were intrigued, as low-dose testosterone replacement therapy was a mainstay of my treatment of menopausal women. Worried about their husbands’ erectile dysfunction, lack of libido, and general health, they asked me if I would treat their husbands. I consented, and soon found myself treating “Joe,” a five-foot, ten-inch, 295-pound man with adult-onset diabetes.
At the age of 48, Joe confided that he was worried about living long enough to see his daughter grow up. Once physically active, he could barely walk up a flight of stairs without becoming breathless. He knew that being diabetic severely affected his heart, and he could not lose weight, though he had tried.After performing a glucose tolerance test with insulin levels, I determined that Joe was an early diabetic. I began administering weekly testosterone injections and monitoring Joe’s blood sugar levels. During the first week of treatment, Joe’s blood glucose dropped into the normal range. He felt better and was able to walk up the stairs without difficulty.
During the first month of treatment, Joe lost 20 pounds without even trying. The second month, he joined a gym and lost another 20 pounds. After the third month, Joe had lost another 10 pounds. After a year of testosterone replacement, Joe weighed 215 pounds—80 pounds less than at the onset of treatment. At 18 months, his repeat glucose tolerance test and insulin and testosterone parameters were normal. Now able to run on a treadmill for 90 minutes, Joe was clinically no longer a diabetic. When his wife received her biweekly testosterone injection, she reported that her husband’s bioidentical hormone replacement program with testosterone was more effective than prescription medications like Viagra® in enhancing his sexual function.
In the hospital, “Hugh,” a 59-year-old insulin-dependent diabetic, was scheduled to undergo amputation of his finger. He had developed an infection from repeated glucose-testing lancets, which had eaten away the tissue all the way to the bone. In the hospital, Hugh was listless, unshaven, had no appetite, and displayed the ominous “Q-sign” (tongue hanging out the side of his mouth). As a family friend, I was beseeched to do something, so I offered an injection of short-acting testosterone. The hospital was in an uproar, as this was considered an unapproved therapy for diabetes.
Hugh’s blood sugar dropped 50 points the first day after the injection, and he got out of bed, shaved, and ate his meals. With two more injections that week, his finger started to heal, and the amputation was cancelled. After Hugh returned home, his wife forbade any more testosterone injections. He no longer suffered from erectile dysfunction. Although Hugh died of cardiac disease four years later, he died with his finger healed and intact.
Clinical Success Leads to Hospital Study
Armed with this information, I approached my colleague James Sowers, MD, a professor at Wayne State University in Detroit. Dr. Sowers is considered one of America’s foremost authorities on diabetes. Dr. Sowers was intrigued by my observations, and we devised a pilot study for diabetic men in 1997. After baseline blood work and testing of their sex hormones (testosterone, estradiol, sex hormone-binding globulin), prostate-specific antigen (PSA), and glucose with insulin, the volunteers would be treated with monthly testosterone implants. They would be seen monthly for three months while on testosterone, and then for four months while off the testosterone injections. Testing occurred at regular one-month intervals.
One limitation of standard medical care is that the physician rarely performs a glucose tolerance test and almost never performs the corresponding insulin measurements. Any deviation from optimal glucose tolerance suggests metabolic syndrome, pre-diabetes, and/or insulin resistance. When blood sugar is high, glucose molecules join hemoglobin, forming glycated or glycosylated hemoglobin in red blood cells, termed hemoglobin A1c (HbA1c). HbA1c levels greater than 6% indicate long-term elevation of blood sugar levels, which has been associated with increased risk of diabetic complications.
In the 1997-1999 pilot study, 35 adult men with diabetes volunteered for treatment. Fifteen men were already on insulin, and 10 were considered “brittle” diabetics, as they used 80-120 units of insulin per day and were prone to precipitous drops in blood sugar called hypoglycemia. Since a hypoglycemic attack can result in coma or death, few doctors aggressively work to lower these patients’ blood sugar levels to achieve a preferred 6% HbA1c blood reading.
Our initial evaluation showed that every man who was diabetic was low in testosterone. (Ten years later, Harvard scientist Eric Ding similarly noted that low testosterone was associated with an elevated risk of diabetes.2) Our laboratory measurements relied not only on the absolute number of total testosterone (reference range: 251-1000 ng/dL), but also on the measurement of bioavailable (that is, circulating and usable) free testosterone.
Having no preconceived expectation, the study followed the insulin-requiring adult diabetics for three months. Most of the participants reduced their insulin requirements by half, without changing their hemoglobin A1c. Men who previously needed 120 units of insulin now needed 60 units; those who previously used 80 units now needed only 40. However, our next observation may be destined to change the treatment of diabetes forever. We found that the diabetic men on testosterone injections not only had better glycemic control, but also had no dangerous hypoglycemic attacks.
Testosterone therapy also produced impressive results in men with adult-onset diabetes who were managing their condition with therapeutic diet and oral medications but not insulin. This group of 20 men comprised two groups. The two-hour glucose tolerance test with insulin showed that six of the men were “early” diabetics, with a pattern of hypersecretion of insulin and low testosterone. With testosterone replacement and a normalization of free testosterone levels, many of these men were able to discontinue their use of oral hypoglycemic agents and improve their HbA1c levels. For those who could not reach an HbA1c level of 6%, therapy was restarted with the most inexpensive generic hypoglycemic agents. These men on testosterone therapy were uniformly pleased with their reawakened vigor, the loss of inches from their waistlines, and improved workout performance.
However, for the 14 men with adult-onset diabetes who were taking oral medications, their personal physicians had not realized they were in fact in the “burned out” stage of the condition, meaning that there was very little pancreatic insulin-producing capacity. The insulin part of the glucose tolerance test showed no fourfold increase in insulin value at one or two hours— instead, the numbers were flat and relatively unchanged. Therefore, these men—who represent more than half of adult men on oral agents—were taking expensive medications that were practically worthless for them. Some of the men were able to achieve better blood sugar control using testosterone alone, while some would eventually develop a need for insulin.