Low Testosterone

Low testosterone levels can cause a variety of symptoms including less interest in sex (low libido), easy fatigue, lethargy, and depression. The onset is usually very subtle, often going unnoticed by the affected individual for many years. In fact, for many cases, the individual never notices the subtle changes in behavior and it is only noticed and brought to their attention by spouses or close friends. 

The condition of low testosterone is also known as Hypogonadism. It occurs when your body no longer makes enough testosterone to satisfy the body’s needs. This leads to feeling fatigued, depressed, as well as having increased body fat, less muscle, diminished sex drive and difficulty with erections.

While the symptoms of hypogonadism are similar to a variety of other medical conditions, it is easy to test and see if low testosterone may be contributing to the problem. A testosterone test measures the level of the male hormone (androgen) in the blood. In men, testosterone is produced largely by the testicles, and to a lesser degree by the adrenal glands. Interestingly, testosterone is also produced in females, although in much smaller amounts than in males. The female hormone system is dominated by estrogen rather than testosterone.

The release of testosterone by the testicle is controlled by a hormone called luteinizing hormone, or LH, which is produced by the pituitary gland in the brain. When the testosterone level is low, the pituitary gland releases lH, which increases the amount of testosterone produced by the testicles.

Before puberty, the testosterone level in boys is low. An increase in testosterone during puberty causes sex organs to mature, sperm to be produced, sexual features to develop (including facial and body hair), enlarged muscles, and a deep voice. The level of testosterone continues to rise during adulthood until it peaks around age 40, then gradually decreases.

Most of the testosterone in the blood is tightly attached to a protein called sex hormone binding globulin (SHBG). A smaller amount is weakly attached to albumin. The tightly bound portion of the hormone is unavailable and inactive; the bioavailable portion (the total of unattached and “weakly bound” testosterone) is the active portion and represents the most important consideration in evaluation. Certain conditions can increase SHBG (such as obesity, hyperthyroidism, pulmonary disease, and certain chronic illnesses). By binding more testosterone, these conditions effectively lower the available “free” testosterone in the system. Simple blood tests can tell if a man’s testosterone is abnormal, and can quantify the different fractions of testosterone (total, free, and bioavailable).

Testosterone Replacement Therapy

If testosterone levels are low, your physician may recommend replacement therapy. There is no safe pill version of testosterone, however, shots, patches, and gels are commonly used. In the natural system, testosterone is released by the testicles in pulses at various intervals throughout the day and night. As such, the levels will vary even during the same day, but they usually will remain within the standard range of 300 – 800 ng/ dl. It is typically recommended to check Testosterone levels between 8 am – 9am.

Current testosterone therapies seek to replace testosterone in a steady, daily fashion. There is now a safe pill version of Testosterone available – Kyzatrex. If you are considering Testosterone injections, usually a single injection in the hip muscle can deliver testosterone that will last for two weeks. Injection will sharply increase bioavailable testosterone, and patients will often experience improved symptoms within a few days. The injection does not allow steady daily levels however, and the levels decrease from the initial high over time. Dosing over the standard levels provides no extra benefit or relief. The body only will utilize testosterone at appropriate levels, and discards the remainder. As an example, your car does not run any better on 7 quarts of oil if 4 will fill it. Current testosterone formulations require an injection every 2 weeks. A longer acting (3-month duration) injection is being developed that aims to provide more stable daily levels and a more convenience injection routine.

Testosterone patches and gels give a more reliable and steady daily dosing of testosterone. Applied each day, the levels of testosterone can be measured and the doses adjusted to reach target levels. Androderm patches are applied daily to a hairless area. They can withstand sweating, bathing, and swimming to some degree. The most common side effects are related to a slight allergic skin reaction to the adhesive.

Testosterone Gels (Testim and Androgel) are clear, colorless gels. They are applied like a lotion to a hairless area of the body, preferably the flanks or shoulders. After application, the user should allow the gel to dry for a few minutes before getting dressed. You should also wait 2 hours before showering, swimming, or exercising (sweating). Make sure to wash your hands after application of the gel, as it could be transferred to others. Transfer usually requires vigorous skin-to-skin contact with fresh gel application. Once the gel has dried, transfer is unlikely. Skin to skin contact with the treated area should be avoided for 3 hours after application. Because testosterone can harm fetus, extra care needs to be taken to avoid transfer to pregnant or nursing females.

Contraindications and Side-Effects

Testosterone therapy should be used with caution in males wanting to maintain fertility. Testosterone use will suppress sperm production, and can make pregnancy difficult. Testosterone therapy should not be considered however, as a reliable form of birth control. Make sure to address this issue with your doctor if you are contemplating testosterone therapy. Your doctor may consider some alternative forms of testosterone that will not impact the production of sperm.

Testosterone therapy should be used with caution in men with enlarged prostate glands, or BpH. Testosterone therapy can accelerate the growth of benign prostate tissue and aggrevate urinary difficulties. If you experience slowing of the urinary stream, frequent urination, increased nighttime urination, or straining to urinate, make sure to discuss this with your doctor.

Testosterone therapy should not be used in males with breast cancer. Although breast cancer is very rare in males, testosterone may affect the progression of the cancer and should be avoided.

Testosterone replacement therapy may also cause a variety of side effects:

• Fluid retention in body tissues, commonly notices as swelling ankles. (Testosterone is a steroid, and all steroids can cause fluid retention)
• Breast Enlargement or Tenderness (males, like females, have glands within the breast tissue, although to a much smaller extent than females. Testosterone may stimulate minor development.)
• Sleep Apnea
• Mood Swings
• Prostate Enlargement (Testosterone can stimulate prostate growth)
• Changes in Cholesterol levels
• Changes in blood counts(hematocrit)
• Acne

If your female partner experiences changes in hair distribution, acne or signs of masculinity, then transfer of the testosterone may be occurring from skin-to-skin contact.

Monitoring Results

For patients on testosterone replacement therapy, several issues deserve particular attention. While testosterone does not cause prostate cancer, testosterone can accelerate prostate cancer growth. Because of this, patients on testosterone need to monitor their PSA, Testosterone levels and hematocrits typically, every six to twelve months. Low testosterone levels can also be associated with the development of osteoporosis. Once diagnosed, men are generally screened to see if the bones have any decrease in density. A DEXA scan can identify those developing any degree of osteoporosis.

To judge the effectiveness of testosterone replacement therapy, a review of the patients symptoms is most telling. Replacement levels can be checked with a simple blood test to see if dosages need to be adjusted. Hematocrit levels (blood count) need to be monitored while on testosterone. Hematocrit levels can rise, and too high of a rise will actually “thicken” the blood. If a significant rise is noted, patients may need to donate blood to help thin out their blood. In general, testosterone therapy will be continued indefinitely, as ongoing testosterone is needed to maintain levels.