Low Testosterone

Low serum testosterone, also known as hypogonadism or andropause, affects 40 percent men over the age of 45. The prevalence of low testosterone also increases with age and includes symptoms such as low libido, irritability, muscle loss, erectile dysfunction, hot flashes and fatigue. For men, testosterone production gradually decreases across the lifespan. Studies have shown that in men over 60 there is a 20 percent increase of low testosterone, a 30 percent rise in men over 70 and a 50 percent increase in men over 80 years of age.


Signs of low testosterone in men

Both non-sexual and sexual signs and symptoms are associated with low testosterone. The former includes increased body fat, reduced muscle mass, depression and decreased energy and fatigue. The sexual signs of low testosterone include low libido, poor erectile function, reduced sexual activity, and weaker and fewer erections.

Low testosterone levels can be found in:

  • 40% of men with high blood pressure
  • 40% of men with high cholesterol levels
  • 50% of men with diabetes
  • 50% of obese men
  • 30% of men with HIV
  • 50% of men with AIDS
  • 75% of men with a history of chronic opioid use

How hypogonadism is diagnosed

To diagnose hypogonadism, a physician will start with an evaluation to determine if your sexual development is at the proper level for your age. Because many of the symptoms of androgen deficiency are non-specific and may be multifactorial in origin, they may not be necessarily linked to low testosterone alone. For this reason, a diagnosis can only be made after detailing your medical history, undergoing a physical examination and by completing appropriate blood tests. Symptoms will be evaluated using questionnaires such as the Aging Male Symptoms Scale or ADAM (Androgen Deficiency in the Aging Male).

A blood test is used to determine low testosterone, and there is controversy surrounding what treatment threshold should be used. This threshold generally ranges from 300 to 400 ng/dL and is dependent on the laboratory analyzing the samples and age of the patient. Men younger than 40 years appear to have hypogonadal symptoms at a higher threshold of 400ng/dL, and men with normal levels should not be prescribed testosterone therapy.

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Treatment Options

Testosterone replacement therapy includes several different prescription options such as topical gel, injections (both short and long acting), long acting pellets, patches and oral inserts. Each method creates hormones that are structurally identical to the ones naturally produced by your body. Many times, your treatment is simply based on your personal preference.

What to expect after treatment?

Following testosterone replacement treatments, men typically experience an improvement in energy levels, muscle mass, libido, depressed moods, sleep and a decrease in body fat. Data has also shown that giving testosterone to a patient with low testosterone may decrease their risk for a bone fracture and increase their bone mineral density. Just like in other chronic conditions, testosterone treatment is considered a lifelong therapy. Stopping treatments will result in a decline in a man's testosterone levels due to testicular and/or pituitary failure.

Physicians will also likely want to check a patient’s PSA level (a screening test for prostate cancer) and his hematocrit level (a measurement of red blood cells in your body). A hematocrit level is checked because men receiving testosterone may experience an increase in their red blood cell count. If the hematocrit exceeds 50 percent, testosterone dosage may be decreased and patients may be asked to donate blood. Dr. Hsieh has published numerous articles on testosterone therapy and management of complications.

Adverse effects of treatment

Prior to treatment, potential adverse effects of testosterone therapy should be discussed. These include hair loss, swelling of the feet or ankles, acne, increased red blood cell count, breast swelling or tenderness, reduced testicular size and infertility. Patients should also be informed that current evidence does claim any definitive answers regarding the risks of testosterone therapy on prostate cancer and cardiovascular disease.

Although the association is weak, the FDA requires manufacturers of approved testosterone products to add labeling information about possible increased risk of heart attack and stroke. However, Dr. Hsieh is a knowledge source who can speak on the risks of the treatments. He was featured in Urology Times on the association between testosterone therapy and thrombotic risk in elderly men. For more information on the adverse effects of testosterone therapy, please read the American Urological Association statement on testosterone therapy.