Testosterone’s Overlooked Role in the Treatment of Diabetes in MenJuly 2007
By Edward M. Lichten, MD
Testosterone Helps Avert Dangers of Diabetes Treatment
When “Charles,” an insulin-requiring diabetic on 100 units per day, came for a follow-up visit, I was surprised to see his finger-stick glucose at the low value of 37 mg/dL. When questioned, he told me that his internist had called him the night before, alarmed at the low glucose reading from a blood sample sent to a national laboratory. Charles had no symptoms, though he knew the symptoms of hypoglycemia and impending coma. I instructed him to reduce his insulin by another 10 units per day, and he agreed to do so. But why didn’t his blood sugar levels crash?
According to the medical literature, including a report by Tiblin,3 testosterone sensitizes men’s cells to more readily admit glucose. In other words, it decreases insulin resistance in men. Therefore, whatever insulin is available in men works much more efficiently in the presence of testosterone. Of note, the female hormone estradiol works counterproductively for men, worsening insulin resistance.2,4
My continuing studies may help explain why the men I have treated with testosterone seem to be protected against developing hypoglycemia and its complications. It is possible that the secondary role of testosterone could be to accelerate not only the conversion of glucose to stored cellular glycogen in the blood, but also to reverse the process when needed, thus accelerating the conversion of stored tissue glycogen to serum glucose.5 This could explain my observation that diabetic men on testosterone injections seem to be protected from hypoglycemia-related coma and death.
Given this unique effect of testosterone, tighter blood sugar control can be more easily achieved. I have routinely lowered insulin-requiring diabetic men from HbA1c levels of 8-11% to a range of 6-7%. This improved long-term blood sugar control could potentially reduce morbidity, mortality, and health care costs by as much as 75%! I believe that widespread implementation of this therapeutic approach could mean fewer heart attacks, strokes, attacks of blindness, and men tethered to dialysis. Diabetic men can and should live longer and live better.
Another interesting patient of mine was “Anthony,” a 50-year-old African-American male without insurance, employment, or regular meals, let alone medication. As shown in Table 1 above, his fasting glucose was 488 mg/dL and his HbA1c was greater than 18%. I immediately treated Anthony with twice the standard dose of testosterone and tracked his blood sugar daily. Over the next four months, I titrated Anthony’s long-acting insulin from 20 units to 90 units per day, and continued a sliding scale of regular insulin at approximately 20 units per day with meals.
What I never expected was how quickly Anthony’s intracellular glycogen stores would normalize. In four weeks, his HbA1c dropped from 18 to 15.7%; at three months, it was 11%; and at five months, it was 7.4%.The Journal of the American Medical Association6 reported that in the best of circumstances, only 40% of insulin-dependent men could achieve an HbA1c level of 8% or lower. Yet I had driven the worst diabetic from a level of 18% to 7.4%. Best of all, the full potential of Anthony’s treatment had not even been realized, since it had been only five months.
Anthony suffered memory lapses originating from the high glucose in his bloodstream and brain tissue. This is not unusual for uncontrolled diabetics. One evening, he injected 30 units of regular, short-acting insulin instead of his usual long-acting insulin. He called me and I advised him to eat his dinner and check his glucose levels every two hours. Anthony’s glucose testing never showed a value below 129 mg/dL. Another time, he awoke at 4 a.m., took his regular insulin, and went back to bed without eating. His morning glucose was in the range of 80-90 mg/dL. Remarkably, he suffered no blood sugar “crash,” coma, or severe symptoms.
As shown in Table 1, no matter how much testosterone was given to Anthony, his total testosterone never exceeded the upper limits of normal for men (1000-1200 ng/dL). He never developed polycythemia, a high red blood cell count that is the most common complication of continuous testosterone injections. (Its solution is simple: donate blood to the Red Cross once every four months.)
I have the same goal as all doctors who treat diabetes: an HbA1c of 6.0%. In my office, with time and cooperation from my patients, almost all men are stabilized with an HbA1c of 6-7%. Glucose levels below 110 mg/dL are common in my patients with diabetes.
Just last year, Dr. Dheeraj Kapoor7 published a study of 20 diabetic men reporting improvement in glycated hemoglobin (HbA1c), fasting blood glucose, insulin sensitivity, waist circumference, and blood lipid levels. Testosterone is an important and beneficial treatment for diabetic men—perhaps even more so than insulin. While insulin is applicable to 10% of men with type II diabetes, testosterone could be useful to almost 100%. Simple, effective, inexpensive, and safe, testosterone is truly man’s best adjunct for a long and healthy life—whether or not he has diabetes.
Risks of Testosterone Therapy
For insulin-requiring diabetic men without contraindications, doctors can administer testosterone injections and follow patients’ improved glycemic control, reducing their insulin requirements accordingly. Not only will the improved glycemic control reduce morbidity (disease incidence), but testosterone replacement may produce beneficial effects for the heart, bones, memory, mood, sexual performance, and red blood cell production, which could reduce the risk of numerous conditions—not only heart attack, Alzheimer’s disease, and osteoporosis, but also dialysis-associated anemia.
In documented cases, men receiving kidney dialysis required less anemia medication when they were receiving treatment with an anabolic steroid.8 If hospitals incorporated testosterone protocols for men undergoing dialysis, more than one third of costs related to anemia medications such as Epogen® might be eliminated.
The risk of infection, bleeding, and potential allergic reaction to the sesame oil used as a carrying agent in the testosterone injection is small. The risks, expounded in the literature, are those related to prostate and testicular cancer. It is a contraindication to use testosterone in the presence of prostate cancer. Yet I have had only one male patient in the last 10 years who developed prostate cancer while on testosterone therapy. In fact, that patient was instructed to go back on testosterone by his doctor at the Mayo Clinic after only two years of observation post-surgery.
A study by Dr. Abraham Morgentaler9 found that testosterone may be protective against prostate cancer. In a large study of men with low testosterone and normal prostate-specific antigen (4 ng/mL or lower), up to one in three had biopsy-proven prostate cancer. Men with total testosterone levels of 250 ng/dL or less had almost twice the incidence of prostate cancer compared to men whose levels were above 250 ng/dL. It is possible that inadequate testosterone levels in men are associated with a higher risk of prostate cancer!
From a medical and health perspective, doctors should have the appropriate laboratory tests performed on all male patients over 35 years of age, especially those with suspected health issues. Without the HbA1c, a physician would not suspect that so many men have long-term elevations in blood sugar. For those who prefer to be tested before seeing a physician, blood tests can be ordered through the Life Extension Foundation.
Thousands of years ago, it was recognized that castration took away a male’s manhood, both physically and emotionally. Today, hormones in our food supply (such as bovine growth hormone) and environmental xenoestrogens (synthetic substances that imitate the effects of estrogens, such as bisphenols and phthalates) may contribute to the dramatic decline in bioavailable testosterone and sperm count that has been observed in American men over the past 50 years. This same period has coincided with a meteoric rise in the incidence of diabetes and heart disease in the US.
Optimizing testosterone levels may provide men with powerful protection against the risk of premature death and diseases such as diabetes, heart disease, osteoporosis, Alzheimer’s, and even prostate cancer.
Edward M. Lichten, MD, FACS, is a Fellow of the American College of Surgeons and a Fellow of the American College of Obstetricians and Gynecologists. Dr. Lichten can be contacted through www.usdoctor.com or by calling 866-532-4254 or 248-593-9999.
1. Moller J. Cholesterol: Interactions with Testosterone and Cortisol in Cardiovascular Diseases. Berlin: Springer-Verlag; 1987.
2. Ding EL, Song Y, Malik VS, Liu S. Sex differences of exogenous sex hormones and risk of type II diabetes.
JAMA. 2006 Mar 15;295(11): 1288-99.
3. Tibblin G, Adlerberth A, Lindstedt G, Bjorntorp P. The pituitary-gonadal axis and health in elderly men: a study of men born in 1913. Diabetes. 1996 Nov;45(11):1605-9.
4. Barud W, Piotrowska-Swirszcz A, Ostrowski S, Palusinski R, Makaruk B. Association of obesity and insulin resistance with serum testosterone, sex hormone binding globulin and estradiol in older males. Pol Merkur Lekarski. 2005 Nov;19(113):634-7.
5. Bergamini E. Different mechanisms in testosterone action on glycogen metabolism in rat perineal and skeletal muscles. Endocrinology. 1975 Jan;96(1):77-84.
6. Hayward RA, Manning WG, Kaplan SH, Wagner EH, Greenfield S. Starting insulin therapy in patients with type 2 diabetes: effectiveness, complications, and resource utilization. JAMA. 1997 Nov 26;278(20):1663-9.
7. Kapoor D, Goodwin E, Channer KS, Jones TH. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes.
Eur J Endocrinol. 2006 Jun;154(6):899-906.
8. Gascon A, Belvis JJ, Berisa F, Iglesias E, Estopinan V, Teruel JL. Nandrolone decanoate is a good alternative for the treatment of anemia in elderly male patients on hemodialysis. Geriatr Nephrol Urol. 1999;9(2):67-72.
9. Morgentaler A, Rhoden EL. Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen levels of 4.0 ng/mL or less. Urology. 2006 Dec;68(6):1263-7.
10. No authors listed. Type 2 diabetes in children and adolescents. American Diabetes Association. Diabetes Care. 2000 Mar;23(3):381-9.