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2020 Clincial Guidelines on Testosterone Therapy: Bad Medicine

The American College of Physicians (ACP) just released (January 7, 2020) new guidelines on testosterone therapy that was published in the Annals of Internal Medicine (1). The authors stated, “The ACP Clinical Guidelines Committee based these recommendations on a systematic review on the efficacy and safety of testosterone treatment in adult men with age-related low testosterone. The target audience is all clinicians and adult men with age-related low testosterone.”


It sounds like the ACP studied the issue thoroughly which should lead to reasonable recommendations for physicians to follow.


In a perfect world, that’s how it should be. However, this a far from perfect world.


Recommendation 1a: ACP suggests that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function (conditional recommendation; low-certainty evidence). The discussion should include the potential benefits, harms, costs, and patient’s preferences.


I have no problem with Recommendation 1a.


Recommendation 1b: ACP suggests that clinicians should reevaluate symptoms within 12 months and periodically thereafter.


I have a lot of problems with this recommendation. Recommendation 1b is a perfect example of BAD MEDICINE.


Recommendation 2: ACP suggests that clinicians not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition (conditional recommendation; low-certainty evidence).


Oy vey! This is a BAD recommendation.


Folks, I have been using testosterone therapy for nearly 25 years. Rebalancing testosterone levels in men and women can provide positive, life-changing benefits. I have seen testosterone therapy lower elevated cholesterol levels, treat depression and mood disorders, improve vitality and muscle strength as well as improving cognition in many of my patients. So, there goes Recommendation 2.


I first wrote about testosterone therapy in 1998 in my book, The Miracle of Natural Hormones, where I wrote about my father’s story. My father, Ellis, suffered with heart disease. He had his first heart attack at age 40 and a second one at age 42. After two bypass surgeries and a few angioplasties, he was on 12 different medications to treat persistent angina (20 years), diabetes and high cholesterol levels. When I learned about holistic medicine, the first hormones I learned about were thyroid hormone and testosterone. I found there was a wealth of research showing a correlation between low testosterone and/or thyroid hormone levels and the development and progression of heart disease. The first natural hormones I prescribed were for my father—natural testosterone and thyroid hormone. Within seven days of starting these hormones, his 20-year history of continual angina melted away—and did not return. Thirty days later, his cholesterol level which was always over 300 mg/dl, fell to below 200 mg/dl without changing his bad habits. And, most importantly, he looked and acted better. He reported (and I saw) his mood and brain function improved. Since that time, I have researched and utilized natural hormonal therapies with great success for my patients.


I have successfully used testosterone therapy in many other patients and seen positive results in every parameter mentioned in Recommendation 2.


As for Recommendation 1b, as I previously stated, it is a perfect example of what is wrong in medicine. Waiting 12 months to reevaluate a patient on any hormonal therapy is ridiculous. With testosterone, one of the adverse effects that needs to be monitored is the hemoglobin and hematocrit. Testosterone can cause the bone marrow to produce red blood cells. Too many red blood cells can make the blood thick and more likely to clot. This can lead to an increase risk in strokes and heart attacks.


The authors of the ACP study cited 38 randomized studies looking at testosterone therapy and various outcomes. The authors did not find compelling evidence that testosterone therapy increased cardiac events or deaths. In fact, the ACP study reported that testosterone therapy resulted in 3.75-fold lower risk of cardiac-related deaths as compared to subjects treated with placebo. Where was this lowered death rate mentioned in the final guidelines?
Testosterone therapy as part of a holistic health program that balances the entire hormonal system as well as corrects nutrient deficiencies can provide very satisfying results. In fact, this holistic approach can provide fantastic health changes. I see the positive results every day in my practice.


These are the benefits of testosterone therapy that I wrote about in The Miracle of Natural Hormones. The benefits include: improving osteoporosis, improving the symptoms of diabetes, increasing a general sense of well-being and improving libido and sexual functioning. In addition, testosterone can decrease negative mood parameters including anger, irritability, nervousness, and tiredness. Testosterone has been shown to prevent and treat coronary artery disease and improve and treat autoimmune disorders such as lupus and rheumatoid arthritis. Also, it has been shown that testosterone has the ability to rejuvenate muscle mass.


What do I think of the ACP 2020 guidelines on testosterone therapy? Fugetaboutit!! I could use stronger language here, but the point is made.


You don’t have to settle for subpar health. It is impossible to have optimal health when your hormones are imbalanced.


More information on bioidentical, natural testosterone and other adrenal and sex hormones can be found in my book, The Miracle of Natural Hormones.


If you need your hormonal system evaluated and balanced, please see one of us at The Center for Holistic Medicine.


Author Info

David Brownstein, M.D.

Comments ( 26 )

  • Author Icon
    Alan Starner

    I don’t take testosterone, but I do take 25 mg DHEA daily – I’m 61. I also have high RBC (5), hemoglobin (18) and hematocrit (51), and have high blood pressure. Could the DHEA be causing thickening of the blood and be contributing to the high blood pressure?
    Thanks for all you do and share!

    • Author Icon

      Have your testosterone levels checked. I have not seen DHEA do that in my patients.

  • Author Icon
    Dick Rumore

    Having a hard time finding a Holistic Doctor in the Tampa Bay Area do you have any recommendation?
    Thanks Dick

    • Author Icon

      Dick, Have the perfect Dr. referral for you in St. Petersburg, Fl. Katarzyna Ostrzenska, MD, medical director of Bay Medical Center. 727-343-6606
      She specializes in bioidentical hormones and is having a seminar at her office Jan 16, 2020-5:30. Call to reserve a spot. Only has 4 seminars per yr and are mandatory for her patients. She has changed my life after years of trying to find the right integrative Dr to help with my autoimmunity.

  • Author Icon
    Peter Tomkinson

    Dr Brownstein, i am not a medical specialist or qualified in health in anyway, a simple fact I put up there to be clear. I also have no health issues myself and hold the highest aviation medical certification (Class 1) at the age of 70 years with so far nothing suggesting I could lose it anytime soon. I still hold a fully valid Airline Pilot Licence with type ratings just to make this point also clear..

    For 35 years or more I have paddled my way through the cardiovascular health issues and then more lately Diabetes. These two are moajor issues for professional pilots and the testing protocols and general focus as well as recommended ‘management’ practices are seriously faulty. Having worked on Pilot technical committees dealing with health issues I have continued my research. It is now my opinion that the focus on cholesterol in Cardio risk is misguided, inflammation IS the issue most commonly. Cholesterol is a care and repair mechanism in my humble view and the question to ask with Cardio is Why it elevates?

    Dr Joseph Kraft, a pathologist in Chicago with in excess of 14,300 subjects demonstrated that in his view as many as 70-80% of ALL north Americans ARE type 2 diabetic. My focus is now to Basal Insulin levels and the implications following a sustained elevated level. This is not divorced from Cardio issues as figures suggest an 8x increase in cardio events and a 4x increase in deaths from cardio events for diagnosed diabetics. Dr Krsft suggested as many as 30% of American who are diabetic do not know it and likely show no obvious symptoms – yet. Maybe their cardio event is in reality a result of a diabetic conditions still not recognised.

    Equally while not in anyway being critical of your clinical practice I find it hard to believe that after 100,000’s of years of human existence that a human is designed by nature to have major health issues due to declining hormone levels, or even such dramatically or critically declining levels simply due to aging. That we deteriorate with age is not the issue as death is inevitable, it is the way we decline and why ,that I think we must look and think about. Our modern lifestyle is nothing like what our human bodies evolved to sustain life with. My ten cents worth.

    • Author Icon

      Good points. As to the declining hormone levels comment…
      Humans have never lived this long. 100 years ago, the average age of death was much lower. I can state, with experience, that my patients report the aging process is improved when the hormonal system is balanced appropriately. Do bioidentical, natural hormones prevent major health issues? Perhaps delay them for some, but, if we live long enough, major health issues will affect us all.
      I can attest to the benefits of testosterone (and other natural hormonal) therapy. I have many patients who can also state the same with testosterone and other hormones.
      There are many factors that promote accelerated aging–hormonal decline included.
      Do they delay mortality? Probably not, but they can help ease the path.

      • Author Icon
        Peter Tomkinson

        I am not convinced that human lifespans were naturally so short as many believe they were. No doubt that early industrial, and early settled peasant conditons were very mean and seriously unhealthy so likely a major factor in lifespan or death rates as for illness generally. I read once that in what was once called the ‘third world’ if an individual could survice the first 6 years of life in reasonable health (what ever that means?) there was every likelihood they would live a long and relatively healthy life – 70 plus years was i think mentioned. Water born pathogens were the major kiler especially f the young.

        Personally I am very wary of what I call “Intervention Medicine’ and while I do not argue blindly against it at all, great care needs be taken so as not to create yet more issues. HRT is a powerful example, Tamoxifen as an Oestrogen blocker is another, and I am sure you could add so many more than I can here. Considering the power and importance of hormones, the interactivity associated with their actions in our bodies, then I tend to see them as something like a catalyst where a little goes a long long way. I think you have argued that Thyroid issues cannot be considered in isolation from Adrenal and Pituitary activity as the three work in a synergistic relationship. The rest of this is line of thinking obvious I hope.

        Given that as is suggested that the human body is about 70% water (yet we do not leak water when pierced – well usually not more than pee!!) which has unique qualities as the universal solvent and a fourth state of matter (solid, liquid, gas and bonded?) together with as much as 90% of ‘our’ DNA being non-human, there is ample if not guaranteed consequences when interventions occur. Interference in the human body can have far more consequence than that intended.

        You are one of those extremely rare medical health providers who are thinking and researching and who do not act without due care. I do not question your motives, the care that means you put the patients interest above your own nor the veracity of the results you have achieved, or more correctly your patients have achieve with your help and guidance. I thank you for your efforts and the information you are providing, yours is a voice I take seriously.

  • Author Icon
    Belinda Meredith

    Hi Dr Brownstein,
    I have followed you and your advice for many years, along with purchasing your books. My father is 86. He had a major heart attack at age 39. At 60, he had cardiac bypass surgery and had a stroke while recovering in the hospital. He suffered another stroke years later. He was on Coumadin for over 20 years until last year when he suffered a hemorrhagic stroke. He recovered, had a watchman device implanted in his heart and is off blood thinners. He has a pacemaker. He has been followed for early bladder cancer in the lining of the bladder for a number of years, which has always been treated And has not returned for several years. He has also had a skin cancer removed. He has also had back surgery and is frail at 86 years old. However, he is mainly frustrated that he cannot do more due to back pain and weakness. I think testosterone may be exactly what he needs and maybe the only thing that will actually improve his situation. He has been on amiodorone, so I’m pretty sure his thyroid is a problem, however, I doubt that anyone will supplement that at this point.

    Most recently, he had worsening heart failure. He had some incidents of a fib, shortness of breath and fluid retention. He had a stress test during this time that showed a decreased ejection fraction from 50 to 37%. Hopefully this may improve since he lost 20lbs of fluid after the initiation of diuretics.

    All this is to ask whether testosterone therapy would be a consideration for him. I have thought for many years that he was one who probably had thyroid disease that was never diagnosed. I have talked to him about that along with testosterone supplementation and also the addition of CoQ10 since he has been on statins for many years. He actually told me that he had asked his urologist about testosterone several years ago but told he was in “the normal range for his age.”

    I almost had him convinced to ask his cardiologist about testosterone therapy at his most recent appointment, but then he changed his mind. I hate to push without knowing if it would be contraindicated for any reason with him. I doubt his cardiologist knows or wants to stick his neck out to find out. So… question……should I continue to suggest testosterone?

    Thank you!

    • Author Icon

      I would ask the question and I would find a doc skilled with prescribing testosterone therapy.

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    Quite concerning that the ACP would make these recommendations for adult patients, and yet give it freely for gender reassignment in the pediatric population. We live in a sick world of medicine, that is making people sicker…physically and mentally!

  • Author Icon

    I asked my physician to place me on testosterone therapy after I discovered (by surfing the internet) that there was a linkage between Low T, hypothyroidism and osteoporosis, all of which I had. I started in 8/18 and have had my levels checked semi-annually. My OP diminished to osteopenia after one year. My dentist is giving me better gum health reviews, and I have increased my weight lifting amounts due to greater strength and stamina. I am very pleased with the results so far. This article was not only an affirmation that I am on the right track, but makes me want to have my cholesterol levels checked next. For decades I have always had readings over 200. One question: I am taking the standard prescription form of testosterone, a topical gel. Is there a better source?

    • Author Icon

      The prescription form of testosterone is a one-size-fits-all method. I prefer individualizing the dosages. Therefore, I use compounding pharmacists who can manufacture many different doses of testosterone.

  • Author Icon

    I am wondering a couple things:

    1.) I know some hormones are derived from pigs. Are there other options for people who don’t ingest pork products?

    2.) I know a young man who is on antidepressants. He is not married and increasing sexual desire would not be helpful. Is there a way to deal with the anger and depression without increasing the sexual aspect? With non-pig products?

      • Author Icon

        Hi Dr B. Saw you 10 years or so ago at Harrahs in LV and have kept u on my radar. Bioidentical hormones have been health savers for my 66 yr old husband and me -72 -for many years. I have no medical issues and Jim has few..
        My question/ concern is my recent “awoke” state from learning about vaccines. Holy mackerel. What can we do to make the general public become aware? The subject is so taboo one has to give a whole series of conversations and articles for someone to take you seriously enough to entertain the subject. Lots of horrible consequences.🤨

  • Author Icon
    Meg Amor

    Aloha David.

    Thank you so much for this. I’m with you. I cannot understand why we spend approximately half our life with our full compliment of hormones on board. Then are expected to simply do without them. It makes no sense. How can we be well when we’re missing vital hormones?

    My sense of it is that probably about 80% of what ails people could be fixed with having their hormones balanced. We ARE our hormones.

    If the condition was diabetes. No one would question the use of insulin. But the sex hormones and thyroid are deemed as piffling unimportant hormones by most hellopathic docs. It makes my blood boil. How can people be this ignorant? And not see the correlation between our hormones and our health.

    Sorry, on a rant. I’m so grateful to docs like you who do the work you do. Thank you.

  • Author Icon

    Wondering about homeopathic testosterone. This would provide all the benefits of crude form testosterone but none of the potential side effects. Just listened to a homeopath discuss its usefulness in men and women with low T signs. She has seen some dramatic turnarounds with low T symptoms. Same for progesterone and thyroid in homeopathic form. Anyone have experience with this?

    • Author Icon

      I have not had experience with homeopathic testosterone but I have with other hormones. I have not observed the same consistent positive responses with homeopathics as I have with bioidentical, natural hormones.

  • Author Icon

    My husband is 75 and has had two heart attacks. Along with COPD and diabetes. He is on so many drugs and his heart is so damaged that his cardiologist told him there is not much more he can do for him as his health has progressively gotten worse over the last 20 years which has greatly impacted our life very negatively.
    I guess I’m just sad he has chosen to go with the flow of ‘modern medicine’.
    Your emails help me learn so much. I’m in much better health at 81.
    Thank you and other like minded doctors who really care. I’m sure that the meds he is on has greatly impacted his testosterone/hormone levels and generally contributed to his ill health.

    • Author Icon

      HI Velma,
      He can easily have his levels checked by his doctor!
      Thanks for the nice comments,

      • Author Icon
        Ira Goodman MD

        There is no question testosterone therapy works well beyond conventional recommendations, if done safely.
        Ilg, MD Board Examiner A4M

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