Testosterone Therapy

Some men have low testosterone levels. This is called Testosterone Deficiency Syndrome (TD) or low testosterone (low T). Deficiency means that the body does not have enough of a needed substance. A syndrome is a group of symptoms that, together, suggest a disease or health condition.

The American Urology Association (AUA) identifies low blood testosterone (low T) as less than 300 nanograms per deciliter (ng/dL). These symptoms or conditions may accompany low T:

• low sex drive;
• fatigue;
• reduced lean muscle mass;
• irritability;
• erectile dysfunction;
• depression.

There are many other possible reasons for these symptoms, such as opioid use, some congenital conditions (medical conditions you are born with), loss of or harm to the testicles, diabetes, and obesity (being overweight). See a doctor if you have any of these symptoms.

Why testosterone replacement therapy (TRT)?

You may need testosterone therapy (TRT) if you have low T. Both the FDA and the AUA suggest that TT be used to treat conditions you are born with, such as Klinefelter syndrome.

You also may need TRT if you harm or lose your testicles. If your testicles are removed because of a sickness such as cancer, you may need TRT. Most men with low T (no matter what the cause) will be treated if they have both symptoms of low T and blood tests showing low T levels.

TRT may help you but it may have adverse (harmful) results. The Federal Drug Administration (FDA) has said that testosterone drug labels should state that there is a risk for heart disease and stroke for some men using testosterone products. All men should be checked for heart disease and stroke before, and periodically while on, TRT.

The AUA however, on a careful review of evidence-based peer-review literature, has stated that there is no strong evidence that TRT either increases or decreases the risk of cardiovascular events.

The FDA also was concerned when they found that men were being treated for low T due only to aging.

How common is low testosterone in men?

It is hard to know how many men among us have TD, although data suggest that overall about 2.1% (about 2 men in every 100) may have TD. As few as 1% of younger men may have TD, while as many as 50% of men over 80 years old may have TD. People who study the condition often use different cut-off points for the numbers, so you may hear different numbers being stated.

TD is more common in men who have diabetes or who are overweight. In one research study, 30% of overweight men had low T, compared to only 6.4% of those with normal weight. The same study found diabetes to be a risk factor for TD. In another study, 24.5% of men with diabetes had low T, compared to 12.6% of those without diabetes.

Symptoms

There are many signs and symptoms of low testosterone. Some are more closely related to low T levels (specific signs and symptoms). Others may not necessarily be linked (non-specific signs and symptoms).

Specific Signs/Symptoms of Testosterone Deficiency (TD)

Specific symptoms are those more likely or directly linked to TD such as:

• reduced sex drive;
• reduced erectile function;
• loss of body hair;
• less beard growth;
• loss of lean muscle mass;
• feeling very tired all the time (fatigue);
• obesity (being overweight);
• symptoms of depression.

Non-specific Signs/Symptoms of Testosterone Deficiency (TD)

Non-specific symptoms are those that may or may not be linked to TD such as:

• lower energy level, endurance, and physical strength;
• poor memory;
• difficulty with finding words to say;
• poor focus;
• not doing well at work.

Having any one of the specific or non-specific symptoms may not mean that you have TD. But if you have a mix of symptoms, for instance, if you start to feel very tired and sad over a period of time and this is a change for you, you may want to check for TD.

Low sexual desire alone may not mean that you have TD. But if you have a combination of low sexual desire, reduced erectile function, and feelings of sadness and tiredness, you should talk to a doctor.

Causes

Some people are born with conditions that cause testosterone deficiency (TD) such as:

• Klinefelter syndrome;
• Noonan syndrome;
• ambiguous genitalia (when the sex organs develop in ways that are not typical-looking).

Some men may develop low T because of conditions like these:

• damage to testicles by accident;
• removal of testicles because of cancer;
• chemotherapy or radiation;
• pituitary gland disease leading to hormone deficiency;
• infection;
• autoimmune disease (when the body makes antibodies that attack its own cells).

Basically, if your testicles keep making less testosterone than normal, your blood levels of testosterone will fall. Many men who develop TD have low T levels linked to:

• aging;
• obesity;
• metabolic syndrome (high blood pressure, high blood sugar, unhealthy cholesterol levels, and belly fat);
• use of medications such as antidepressants and narcotic pain medications.

Men with certain health problems also tend to have low testosterone. Some of these are:

• HIV (about 30 out of 100 also have low testosterone);
• AIDS (about 50 out of 100 also have low testosterone).

Diagnosis

Although many symptoms may be tied to low testosterone (low T), total blood testosterone level is the most important measure of testosterone deficiency. To make a diagnosis, your doctor will use other specific signs and symptoms in addition to your testosterone blood level.

At your medical visit, your health history will be taken, and the doctor will do an exam and look for some of the signs and symptoms mentioned in this article.

Health History

A doctor may ask you about:

• headache, visual field change (possible symptoms of brain mass such as a pituitary tumor);
• how you developed at puberty;
• history of head trauma;
• cranial (head) surgery/brain tumor or cranial irradiation;
• anosmia (loss of ability to smell);
• history of infection in your testicles;
• injury to your testicles;
• mumps after puberty;
• the past or present use of anabolic steroids;
• use of opiates;
• use of glucocorticoids (medicines, such as cortisone, used to treat inflammation);
• history of chemotherapy or irradiation;
• family history of diseases linked to low T;
• history of stroke or heart attack;
• history of unexplained anemia.

Physical Examination

A doctor will check for the following:

• BMI or waist circumference for obesity;
• metabolic syndrome. These are symptoms (seen together) of increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels;
• hair pattern, amount, and location;
• gynecomastia (enlarged breasts);
• whether testicles are present and their size;
• prostate size and any abnormalities.

Testing

A doctor may order these blood tests:

• Total testosterone level. This test should be done at two different times on samples taken before noon. Testosterone levels are lower later in the day. If you are ill, the doctor will wait until you are not sick because your illness may cause a false result.
• Luteinizing hormone (LH). This test is done to help find the cause of a Low-T level. This hormone controls how you make testosterone. Abnormal levels may mean a pituitary gland problem.
• Blood prolactin level. If your prolactin level is high, your doctor may repeat the blood test to make sure there is no error. High prolactin levels also may be a sign of pituitary problems or tumors.
• Blood hemoglobin or Hgb. Before doing this test, your doctor will look for other reasons for low Hgb such as climate level (like climate altitude), sleep apnea, or tobacco smoking.

The following also may be done to help with further diagnosis:

• Follicle-stimulating hormone (FSH). This test is to check for sperm-making function if you want to have children. You may also need to have semen tests. These tests will be done before any hormone therapy.
• Estradiol hormone test is done if there are breast symptoms.
• HbA1C blood test may be done for diabetes.
• MRI ( magnetic resonance imaging) of the pituitary gland
• Bone density tests.
• Karyotype (Chromosome tests).

You may hear about free testosterone or bioavailable tests for testosterone. These are not the same as total testosterone level tests. Ask a doctor about the differences and if you need these tests.

Treatment

In recent years, the media has reported more about testosterone therapy (TRT), and more men between the ages of 40 and 64 have been tested and given TRT. Some men with certain symptoms may even want TRT without being tested. This action may not be safe or helpful for them. Total testosterone level should always be tested before any TRT.

The AUA recommends that TRT be prescribed only to men who meet the clinical and laboratory definition of testosterone deficiency (testosterone level of less than 300 ng/dL). Here are some of the things you will need to know about TRT:

A doctor will likely measure your testosterone level if you have these conditions:

• • unexplained anemia;
  • diabetes;
  • bone density loss;
  • low-trauma bone fracture;
  • radiation to your testicles;
  • HIV/AIDS positive test results;
  • chronic narcotic use;
  • history of infertility;
  • pituitary gland disorders.

Even if you do not have specific signs and symptoms, your doctor may test your total testosterone level for these conditions:

• insulin resistance;
• history of chemotherapy;
• history of using corticosteroid medicines;
• health changes such as losing weight and getting more physical activity will likely raise your testosterone levels.
• A doctor will want to check your hemoglobin/hematocrit (Hgb/Hct) levels while you are on TRT. This blood test will help check for the thickening of the blood.
• Blood thickening may cause blood clots. A doctor may do Hgb/Hct levels two to six weeks after you start TRT and every six to twelve months after that test.
• If you are at risk for heart disease, a doctor will follow you more closely when you are on TRT. It also is important to make healthy changes to decrease the chances of heart and blood vessel disease.
• A doctor will treat your low T level to raise it above 300ng/dl but the exact level may vary.
• A doctor will watch you for signs and symptoms of improvement. Any changes will likely appear within three to six months of treatment.
• If your total testosterone blood level returns to normal and you still have symptoms, it is likely that there are other reasons for your symptoms. A doctor may stop TRT and try to find out what else might be the problem.

How do I take testosterone?

There are generally five different ways to take testosterone. They are transdermal (through the skin), injection, oral/buccal (by mouth), intranasal (through the nose), and pellets under the skin. No method is better than another. While you are taking TRT, your doctor will test your blood to determine testosterone levels.

Here are some details about the five different methods:

• Transdermal (Topical). There are topical gels, creams, liquids, and patches. Topical medicines most often last for about four days. They absorb better if covered with an air- or water-tight dressing.
  • Apply liquids and gels, creams or patches to skin that is dry and without cuts or scratches.
  • Do not wash the area until it is time for the next dose.
  • Wash your hands after you apply liquids, gels or creams.
  • Make sure that other people, especially women and children, do not touch the medicines.

A topical patch is like a band-aid with medicine on it. You put it on and leave it until the next dose is due. The medicine on the patch is less likely than liquids, gels, and creams to transfer to others.

• Injection. There are short-acting and long-acting forms of testosterone injection. The short-acting medicine may be given under the skin or in the muscle. The long-acting one is usually given in the muscle. Injections are usually given either weekly, every two weeks, or monthly.
• Oral/buccal (by mouth). The buccal dose comes in a patch that you place above your incisor (canine or “eyetooth”). The medication looks like a tablet but you should not chew or swallow it. The drug is released over 12 hours. This method has fewer harmful side effects on the liver than if the drug is swallowed, but it may cause headaches or cause irritation where you place it.
• Intranasal. This form of testosterone comes in a gel. You pump the dose into each nostril, as directed. It is usually taken three times daily.
• Pellets. A doctor will place the testosterone pellets under the skin of your upper hip or buttocks. A doctor will give a shot of local anesthesia to numb your skin, then make a small cut and place the pellets inside the fatty tissues underneath your skin. This medication dissolves slowly and is released over about 3-6 months, depending on the number of pellets.

You may want to choose how you take your testosterone based on what is best or most useful for you. In some cases, your insurance provider may decide the order in which testosterone therapies are provided. Talk about the choices with your doctor.

After Treatment

Remember that each person is unique, and each body responds differently to a treatment. TRT may help erectile function, low sex drive, bone marrow density, anemia, lean body mass, and/or symptoms of depression. However, there is no strong evidence that TRT will help memory recall, measures of diabetes, energy, tiredness, lipid profiles, or quality of life.

You will need routine checkups to see that your testosterone level stays normal. In patients who are stable on TRT, total testosterone and certain other lab tests should be checked every 6-12 months.

If you are overweight, try to work on keeping your weight within recommended ranges. Increasing physical activity may help you lose weight and also may help increase testosterone levels.

For more concerns, don’t hesitate to contact our team here.