It's a scary thought, but in some ways, doctors seem to be a lot like teens on TikTok – both groups have a tendency to fall for stories that don't have a lot of factual basis. It's funny on TikTok; it's frightening when it comes to medical mistakes and health myths.
Don't believe me? Take a look at the following list of things that many doctors accept as gospel even though they seem to be based on casual observations made a long time ago. Others on the list are simply examples of intellectual laziness.
At the very least, each of the following medical "facts" needs a little extra intellectual scrutiny before doctors continue to use them to determine the health care of millions.
Back in the 1940s, doctors didn't know much about prostate cancer (or any cancer, for that matter). However, they noted that men with metastatic prostate cancer lived a bit longer when they were castrated.
I should rephrase that. They noted that ONE man with metastatic prostate cancer lived longer when he was castrated. (1) That's right, the effects of castration on one poor bastard's prostate cancer led several generations of doctors to assume that it was testosterone itself that promoted the disease. Mind boggling, isn't it?
The Opposite Seems to Be True
The preponderance of evidence shows that men with low testosterone don't have anything to fear from TRT (testosterone replacement therapy). It won't increase their risk of developing prostate cancer.
Consider the analysis of more than a quarter of a million records of men in Sweden that was released at the annual meeting of the American Urological Association in San Diego, California in 2016.
The researchers found that men who'd been prescribed testosterone for longer than a year not only had no overall increased risk of prostate cancer, but their risk of aggressive disease had been reduced by 50 percent.
And this is only the most recent of many studies that squelch the myth that TRT causes prostate cancer. Researchers in the United Kingdom looked at 1400 men who had received testosterone replacement therapy for up to 20 years and they found only 14 cases of prostate cancer over the course of the study. (2)
This prompted the co-author of the study, Dr. Malcolm Carruthers, medical director at the Center for Men's Health in London, to state:
"This myth about testosterone replacement therapy being linked to prostate cancer has been rooted deep in medical consciousness for over 60 years, but this paper says no. Testosterone treatment is actually good for the prostate, not bad."
Back in 1904, some French doctors reported that six of their patients had high blood pressure. They also noted that the same patients used a lot of salt on their food. That's all it took to get salt phobia rolling for the next hundred years. No clinical evidence, just the most casual of observations.
Worries intensified in the 70's when Lewis Dahl from the Brookhaven National Laboratory reported that he had "unequivocal" evidence that salt was linked to high blood pressure.
Too bad nobody really read the fine print in his study. Yes, feeding sodium to rats caused them to develop hypertension, but he fed them the human equivalent of 500 grams of sodium a day. The trouble is, the average American only consumes about 3.4 grams a day.
Doctors continued to take these warnings seriously, though, probably because the follow-up studies were either small or underreported. But then, in mid-2011, the American Journal of Hypertension published a meta-analysis of seven studies involving 6,250 subjects.
The study reported no strong evidence that cutting salt intake would reduce the risk of stroke or heart attack in people with normal or high blood pressure.
Another study, this one from the American Journal of Medicine, looked at the daily salt intake of 78 million Americans. It found that the salt intake correlated negatively with death rate. In other words, the more salt people ate, the less likely they were to die from heart disease.
However, one big meta-report, funded by the U.S. Department of Health, did find that cutting salt intake reduces blood pressure. They looked at the result of 11 salt-reduction studies and found that low-salt diets did indeed decrease systolic blood pressure by an average of 1.1 millimeters of mercury and diastolic blood pressure by 0.6 millimeters of mercury.
Ho-hum. According to science writer Melinda Wenner Moyer, writing in Scientific American, "That's like going from 120/80 to 119/79." (3)
Before I give the impression that the more salt you eat the better, I need to add that a certain segment of the population really is salt-sensitive, and that excess sodium can raise their blood pressure. The vast majority of people are safe, though, since the connection between salt intake and high blood pressure is, for them, largely a time-honored myth.
Even so, blood pressure readings might not be the most important barometer of heart health. See "myth" number five.
Doctors routinely order PSA tests for their male patients, but do these tests sometimes do more harm than good? That sure seems to be the case. Chew on these assessments by the US Preventative Services Task Force regarding PSA testing:
- If 1,000 men ages 55 to 69 get tested regularly for 10 to 15 years, 240 of them will test high enough for PSA that they require a biopsy.
- One hundred of these men will get bad news from the lab.
- Eighty of them will require surgery and/or radiation, and 60 will suffer side effects from this treatment, including incontinence and impotence.
- Only one to two prostate cancer deaths will be prevented.
Additional data from the task force concluded that you're 120-240 times more likely to be misdiagnosed as a result of a positive PSA test and 40-80 times more likely to get unnecessary surgery or radiation than you are of having your life saved. (4)
As bad as that task force's findings were, it was kinder to PSA tests in general than another analysis done in 2013 by the Cochrane Group, an international collaboration that provides impartial assessments of medical procedures.
The group carried out a meta-analysis of five major studies of the PSA test, including the U.S. and European trials. The combined data showed "no significant reduction in prostate cancer-specific and overall mortality."
The report added:
"Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity... Common major harms include over-diagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence."
Even the guy who discovered PSA, pathologist Richard J. Ablin, called it a "profit-driven public health disaster" because it led to approximately 30 million American men being tested every year at a cost of at least 3 billion dollars. (5)
As hackneyed as PSA testing is, those men who have some sort of familial history of prostate cancer (especially if a brother has had prostate cancer) should probably have the test done anyhow.
The rest of us, however, might want to at least be aware of possible fallibilities associated with the test before we let the doc check the PSA box on the lab requisition form.
Abraham Morgentaler, MD, is a testosterone-science hotshot who's well known to those of us who are passionate about the hormone. In 2006, he and his colleagues did a survey of 12 academic laboratories, 12 community medical laboratories, and one national laboratory. (6)
Of the 25 labs they surveyed, there were 17 different sets of values for total testosterone and 13 different sets of values for free testosterone:
- Reference values for low testosterone ranged from 130 to 450 ng/dl, a 350% difference.
- Reference values for the upper end of "normal" ranged from 486 to 1,593 ng/dl, a 325% difference.
The widest range for supposedly normal total testosterone levels from a single lab was 262 to 1,593 ng/dl and the narrowest range was 180 to 486 ng/dl.
As far as free testosterone levels, the low value ranged from 5.0 to 13.5 picograms per milliliter, a variation of about 270%. The upper value ranged from 19.0 to 54.7 pg/ml, a variation of about 290%.
Are you getting the implications of this? As Morgentaler and his colleagues pointed out, a man who had a total testosterone reading of 251 ng/dl would be categorized as hypogonadal by 14 of the labs they surveyed and normal by the other 11 labs. They noted similar results for free testosterone.
Shoot forward in time ten years later. Researcher Margaret Le and her colleagues from the Urology Department of the University of Kansas Medical Center undertook a study similar to Morgentaler's, only more comprehensive. (7) They interviewed 120 laboratories from 47 states.
They found a range of 160 to 300 ng/dl for the lower reference value of total testosterone and a range of 726 to 1,130 ng/dl for the upper.
Further, they found that a third of the labs "age stratified" reference values. As an example, 19 of the surveyed labs arbitrarily designated 50 years or greater as kind of a statistical cutoff age, meaning old coots were assigned different definitions of normal total testosterone levels.
Other labs reported ranges by decade of life (i.e., separate ranges for men in their twenties, thirties, forties, etc). Still others divvied up men into three age groups: 18 to 39, 40 to 59, and greater than 60.
Can you see the problem with this age stratification?
Let's say you just turned 40 and you suspect your T levels are low. You go to the doc to get your levels checked and they come back "normal" for a man your age. However, if you had gotten the test the day before you turned 40, you might have tested low and qualified for TRT.
What a mess.
Don't get me wrong, accurate blood pressure readings are a somewhat reliable indicator of your risk for heart attack or stroke, but I'm betting there are millions of people – particularly weight lifters – who are unnecessarily taking medications for high blood pressure.
For one thing, hardly any doctor, nurse, or physician's assistant takes blood pressure readings accurately. Let me prove it. Has any medico advised you do any of the following before taking a reading?
- Avoid stimulation. Don't drink coffee, exercise, or smoke within 30 minutes of the test.
- Relax. You need to sit in the room quietly for at least five minutes before anyone attempts to take your BP. Then, when they take it, don't talk.
- Sit the right way. You need to be sitting in a regular chair with a back, your feet flat on the floor (and don't cross your legs). Don't merely sit upright on the exam table.
- Empty your bladder before the test.
- Position your arm correctly. Your upper arm must be supported at mid-heart level, and your elbow must be bent at a 45-degree angle.
Furthermore, accurate measurements need to be obtained from two careful readings on at least two separate occasions. Ignoring any of these guidelines could give inaccurate numbers and lead to a false positive, prompting the doc to prescribe medicines you don't need.
There's one more thing you need to watch out for, too, particularly if you're a lifter.
Big Boys Need Big Cuffs
A few years back, researchers at the Mexican Universidad de Guadalajara conducted a study on two hundred bodybuilders who'd just competed in the Mexican National Fitness and Bodybuilding Championships. (8)
The researchers wanted to see if arm size influenced blood pressure readings, so they measured the BP of all of them using both a standard (medium) cuff and a large cuff.
There was no difference between readings using the standard cuff and the large cuff, as long as the subject's arm circumference was less than about 13 inches (that measurement seems small, but there were a lot of women in the show, too). However, things went screwy when the subject's arm circumference was above 13 inches and the medicos used the standard cuff.
On average, the standard, ill-fitting cuff caused their systolic blood pressure (the top number in BP reading) to trend about 8 points higher.
What this means is that if you've lifted weights for any length of time, your arm circumference is likely too big for the standard cuff and you're going to get a false positive. Sweet-talk the person taking your BP to go into the closet and blow off the dust from the big boy cuff.
If all these recommendations have been followed and all these precautions observed, then and only then can you get an accurate blood pressure reading.
Even so, there's something that's a far better predictor of diseased arteries and future heart problems than blood pressure.
A healthy endothelium (the single-cell layered tissue that lines blood vessels, the heart, and the lymphatic system) is essential to a good, strong, serviceable erection, just as it is to blood flow throughout the body. While an unhealthy endothelium leads to erectile dysfunction (ED), it's also a strong predictor of heart disease and premature death. Simply put, bad erections often equal bad hearts.
Cardiologist Joel Kahn, a proponent of the erection/heart health theory, points out the following alarming bit of epidemiological data from a specific area, but one that could easily apply to anywhere (9):
"...if you live in Olmstead County, Minnesota, and are a man between the ages of 40 and 49 without known heart disease but with ED, you have up to a 50-fold higher incidence of eventually having new heart events compared to men the same age without ED. Rarely in medicine is there ever a risk factor this powerful. To compare, smoking, for example, may raise the risk of similar events three-fold."
In another example, if a man who has diabetes is unable to achieve a strong erection, it can predict diseased arteries and future heart problems years before a heart attack or death from heart-related problems. The correlation is much stronger than that of smoking, elevated blood pressure, or family history of heart disease.
- Morgentaler A. Testosterone and prostate cancer: an historical perspective on a modern myth. Eur Urol. 2006 Nov;50(5):935-9.
- Feneley MR MD et al. Is Testosterone Treatment Good for the Prostate? Study of Safety during Long-Term Treatment. The Journal of Sexual Medicine. 2012 Aug;9(8):2138-2149.
- Moyer MW. It's Time to End the War on Salt. Scientific American, July 8th, 2011.
- Horgan J. Why I Won't Get a PSA Test for Prostate Cancer. Scientific American, June 14, 2017.
- Ablin R MD The Great Prostate Mistake. The New York Times, March 9th, 2010.
- Lazarou S MD et al. Wide Variability in Laboratory Reference Values for Serum Testosterone. J Sex Med. 2006 Nov;3(6):1085-1089.
- Le M et al. Current Practices of Measuring and Reference Range Reporting of Free and Total Testosterone in the United States. J Urol. 2016 May;195(5):1556-1561.
- Fonseca-Reyes S et al. Differences and effects of medium and large adult cuffs on blood pressure readings in individuals with muscular arms. Blood Press Monit. 2009 Aug;14(4):166-71.
- Kahn J MD. Survival of the Firmest: What Your Erection Says About Your Health. Mind Body Green. April 17, 2014.