About Low T
Click here to read the Texas Urology Opinion on the recent JAMA study linking Testosterone and Heart Disease.
Many men as they age, face symptoms of low testosterone (low T), such as low energy and low sex drive. There has been a lot of discussion and research on menopause in women, however, not until recently has there been a spotlight on low testosterone (low T) in men. Some have called this “Andropause”. Low testosterone affects about 40% of men over the age of 45. As men age, their levels of testosterone may decrease. Increasingly people are mentally, physically and sexually active much later in life than their parents or grandparents were. This awareness of low testosterone is only magnified by the numerous “Low T Centers” that are popping up in advertising in newspapers, radio and TV.
What is Low T (Low Testosterone)?
What exactly is a low T level? Check on the internet or any lab guideline and you’ll see a significant range of what is normal. Interestingly, guidelines vary between international and national societies. Normal ranges used in clinical labs are based on normal ranges of healthy young men. Ranges can also vary between countries and labs. According to the Endocrine Society, men should not be treated unless levels are below 300 and asymptomatic men should not be screened for low testosterone. While we do not have a set value that we find acceptable, it truly depends on what a man’s symptoms are. Remember, we cannot jump-start a man’s testosterone and testosterone replacement therapy is intended, theoretically, for life. It is not unreasonable to believe that different men will need different testosterone levels to feel well. Certainly, it does help to have previous levels to compare as a baseline to see if there is an abnormal drop. This reinforces the idea that low T may not be the only factor in low energy, libido or other signs of low T. The situation is only further confused by the fact that many other disease processes including obesity, depression and even sleep apnea can manifest the same symptom complex. On the other hand, numerous studies have linked low testosterone with a metabolic syndrome and, at least within the urologic literature, it is considered one of the components.
Symptoms of Low T
Low libido or sex drive
Fatigue/lack of energy
Decreased focus or concentration
Decreased strength or endurance
Decreased muscle mass
Decreased bone mass
Increased fat mass
Testosterone levels tend to decrease with age, normally at 1-2% per year. After the age of 30, men may start noticing the symptoms of low T. Causes of low T may also originate higher up on the hormonal axis. As you know FSH (follicle-stimulating hormone), LH (luteinizing hormone) and prolactin affect testosterone production in the testicles. When these hormones are abnormal, T levels may be decreased. Other less common causes include increased estrogen levels, trauma to the testicles, and anabolic steroid use. Studies have also shown the depression of the hormonal axis in men with chronic pain on narcotic therapy.
Although many people may find that low T is their primary issue, some people will still find that other issues, some medical and some non-medical (work or life stressors) may be a significant source of their symptoms. Low T can also result in a loss of self-esteem and confidence. It is also important to know that a fall in libido or sex drive can also be commonly associated with medical conditions such as depression, anxiety and other disease states.
Testosterone is found in the circulation either loosely bound to albumin, tightly binding to sex hormone binding globulin or unattached ( free testosterone). When one orders a serum testosterone, one gets the sum of all three components. In actual fact, free testosterone, approximately 1-2%, is the active component and can be measured separately. While one can do blood tests for sex hormone binding globulin, bioavailable testosterone, in fact, a total and free testosterone is all that is necessary. We certainly believe that men with low free testosterone, even with normal testosterone levels, could benefit from replacement therapy.
A thorough evaluation should be performed on each patient that exhibits symptoms of low testosterone. Since symptoms can be caused by other medical conditions, a comprehensive lab panel covers for other reasons patients may be experiencing low libido, fatigue and erectile dysfunction. Screening includes free and total testosterone, TSH, estradiol, hemoglobin A1C, lipid panel, PSA, CBC and Chem 7. Men with a questionable history of sleep disorders, such as sleep apnea, should consider diagnostic testing, not only as a cause of the symptom complex but because the potential of an exacerbation of sleep apnea with testosterone therapy is possible.
No. 1: There is no study in urology literature that has demonstrated that testosterone replacement therapy is associated with production of prostate cancer. In fact, a potential risk factor for prostate cancer is low testosterone. This having been said, any man on testosterone replacement therapy needs to have baseline and follow-up PSAs. Statistically, some of these men will develop prostate cancer and it is important to be able to monitor them more closely for medical legal reasons.
No. 2: Testosterone replacement therapy is contraindicated, according to the FDA, in the face of a history of prostate cancer. This having been said, numerous articles are appearing in urological literature indicating that it is reasonable to treat these men. This is not something we feel primary care physicians should currently get involved with and, in fact, we will have a separate up-date on this topic.
Treatment for low testosterone is based on symptoms and correlating labs. Treatment is delivered through testosterone supplementation or by increasing FHS and LH, which, in turn, drive testosterone production.
Testosterone supplementation is delivered through a variety of methods including topical gels, creams, subcutaneous pellets, oral tablets and injections. We typically recommend starting treatment with a topical gel which steadily and consistently increase T levels. A testosterone level should be checked 2-3 weeks after starting therapy at least 2 hours after application. With all forms of gel there is a FDA black box warning for potential exposure to women and children. All men should be instructed on proper application, cleanup and minimizing exposure to others. This should be documented in the chart.
It is important to monitor testosterone levels on treatment as well as improvement in the patient’s symptom complex. As we previously stated, just because a man’s testosterone level is within the normal range does not mean we will have resolved his symptoms and it is not unreasonable to consider increasing the dose of replacement therapy.
It is important to note that testosterone replacement therapy can be associated with decreasing sperm count. Therefore, we would urge strong caution and possible consideration of referral to an endocrinologist in men who are interested in having a child or additional children instead of simply placing them on testosterone replacement therapy.
Men on testosterone replacement therapy should be followed once adequate resolution of the symptom chronic complex and normalization of testosterone levels with every 6 month PSAs, testosterone levels, and H & H. In our practice, men on depo-testosterone replacement therapy, have elevated hematocrit and hemoglobin at least 60% of the time. In fact, we encourage and often insist these men donate blood on a regular or increased frequency in order to keep their hemoglobin levels in an acceptable range. While, less common, this can also occur in men using topical therapies.
Lifestyle changes are key in overall treatment of patients, as well as a regular follow-up with a Primary Care Provider. Here are some lifestyle modifications which can help relieve low T related symptoms.
Maintaining a healthy diet
Increasing cardiovascular exercise
Regulating a proper sleep schedule
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