Hypogonadism or low testosterone is a common condition seen in men as they age. Testosterone is the male sex hormone produced primarily by the testicles. The testicles are stimulated by secretion of LH and FSH by the pituitary gland to produce testosterone (T) and sperm respectively. Women also have testosterone, but in much lower levels.
What are the Symptoms of Low Testosterone?
Signs and symptoms of low T in older men include lack of energy, focus, increased body fat, depression, diminished muscle mass and most commonly low libido and poor erectile function.
The Endocrine Society and AUA guidelines define Hypogonadism as T levels less than 300 ng/dL and symptoms consistent with low T. The diagnosis needs to be confirmed with two morning blood tests, on different days. Low T is defined as primary or secondary depending on the source of the problem. Primary Hypogonadism, being testicular dysfunction, is seen with testes cancer, or genetic conditions such a Klinefelter’s. Secondary Hypogonadism is due to pituitary dysfunction. The vast majority of hypogonadal men have a hybrid form commonly called Hypogonadism of aging men. This has also been referred to as andropause or male menopause. It differs from menopause in that in men the hormone levels drop much more gradually over time and many men maintain normal levels. Conditions that are associated with low T include Type 2 Diabetes, obesity, HIV disease, metabolic syndrome, and opioid use.
Do Effective Treatments Exist?
There are many treatments for low T that can either stimulate the pituitary gland (Clomid, HCG) or replace T directly. The first oral T, Jatenzo was recently approved, other treatments include weekly injections, long acting pellets or daily gels. The T Trial published in the New England Journal of Medicine was the largest placebo controlled trial, and it looked at the benefits of T replacement. It showed improved aspects of sexual function, improved walking distance, and slightly improved mood.
Testosterone therapy is not without potential risks and men on testosterone must be monitored. While men with low T have many increased risk factors for cardiac disease, several retrospective trials have shown increased adverse cardiac events in men on T replacement. Despite the many questions about the veracity of these trials, the FDA released a warning statement about the potential cardiac risk associated with testosterone replacement. A large randomized trial, the traverse trial, is presently underway to evaluate potential cardiac risk.
There is a black box warning on labels of recently approved T products regarding increased blood pressure seen in a small number of men receiving T replacement. The gels have a black box warning about possible transference of the gel to others.
Other concerns or side effects of T replacement include decreased fertility, as exogenous T suppresses testicular function including sperm production. There is potential for increased red blood cells which can thicken the blood. There is a theoretical concern of increased prostate cancer or enlargement of the prostate. Morgentaler et al has written extensively about this potential risk and has largely debunked this concern. That said, men on testosterone replacement should have regular PSA blood tests and digital rectal exams.
Who Should get Screened for Low T?
According to the aforementioned guidelines, men with erectile dysfunction, infertility, low libido, Type 2 diabetes, obesity, depression and atrophic or small testicles should be screened with a morning T level.
Men should speak to their doctor about what treatment for low T is most appropriate for them. Non-pharmacological ways to boost testosterone include weight loss, healthy diet, improved sleep, and weight training. Long distance running, some medicines such as statins, and diets high in estrogenic foods, such as soy products, can in some cases lower T levels.
Testosterone should always be administered by a medical practitioner trained and focused on men’s health and never use testosterone obtained in the gym or from friends or trainers.
While T is not a panacea or fountain of youth, it can be transformative in many men if used properly. It can boost libido, improve sex drive and erections and improve the quality of orgasm. Many men report improved energy and vigor. Levels should be followed and dosage changed according to levels and improvement of symptoms.
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