Our understanding of aging keeps changing. With more and more Americans living to old age, and with the “boomers” changing the “look” of aging, it is fitting that our first issue in 2007 is permeated—from the In-Depth article to Geriatrics, to Women’s Health and Men’s Health—with the question of the clinical significance of replacing or supplementing hormones, including testosterone, estrogen, and dehydroepiandrosterone (DHEA), with so-called chemical or natural products.

New pharmaceuticals are constantly being developed to replace depleting hormones in older age, even as the debate between physicians and pharmacists continues about the benefits and risks of these products, as illuminated in the In-Depth article.

The repercussions of the Women’s Health Initiative notwithstanding, patients and physicians continue to look for new hormone therapies for men and women, with the hope of prolonging youth and averting some of the “less desirable” consequences of aging. Ongoing research suggests that restoring more features of youth may one day be more than a Hollywood fantasy, but how to translate this into a meaningful clinical benefit remains elusive.

A new study published in the New England Journal of Medicine and discussed in this issue shows that using supplemental testosterone or DHEA does restore bioavailable levels of the hormones, but this does not translate into a meaningful impact on physical function, at least as measured in this study.

Previous studies conducted by sexual medicine experts have shown that the use of testosterone or DHEA in androgen-deficient women can restore sexual function and improve overall well-being. But replacing biologic hormones may not be as simple as taking a pill, and the risks are many. Perhaps we also have to rephrase some of the questions asked by researchers?

By now all physicians are cognizant that supplementing reproductive hormones does offer benefits to some people, but safety questions linger. It is therefore curious that no research has been devoted to the potential risks associated with very low levels of these hormones.

Now for the first time a new study reported at the recent meeting of the American Heart Association indicates that older women who have low levels of testosterone are at a significantly increased risk for coronary heart disease (CHD). This finding “elevates” hormone therapy concerns to “mainstream” medicine, and while awaiting further research to define the approach to therapy, you have to decide whether to leave such CHD risk unmanaged. Another study shows that high levels of endogenous estradiol are associated with fewer fractures. Could this be another venue for new therapies?  

And the introduction of the phosphodiesterase type 5 (PDE-5) inhibitors at the end of the twentieth century opened a new world of sexual well-being for older men (and women). But as is often the case in medicine, with progress come new risks. With billions of prescriptions for the 3 PDE-5 inhibitors and the potential for misuse, a growing number of seizures are being reported with these agents, especially at high doses.

So although the “long-life pill” is not here yet, improving well-being in old age is increasingly attainable, at least when chronic diseases are not involved. And since all medicines come with some risks, even statins, explaining potential harm and correct use, especially to older patients, remains a key clinical task.