Technically, one should seek medical care or attention for low testosterone at either of two times: 1) when hypogonadic (low testosterone) symptoms, at any age, begin to manifest and/or hinder one’s quality of life; or 2) when it is suspected that testosterone levels are no longer within the optimal range, and may be reducing one’s full potential with or without presenting hypogonadic symptoms. Furthermore, since hypogonadic symptoms occur gradually, and can often be very subtle especially as one’s age increases, it is a good practice to have testosterone levels routinely tested after age 40, the age at which annual male check-ups should begin. Whether it’s a hindrance to one’s lifestyle, or merely causing less than optimal internal and/or external bodily conditions, in either case testosterone therapy may be warranted. This article includes a bevy of low testosterone information including its primary symptoms, how it is diagnosed, the main forms of therapy medications, and more all of which aid in determining when and if one should seek medical care for low testosterone.
Low Testosterone Symptoms
Identifying low testosterone greatly reduces the odds of misinterpreted symptoms, which can lead to misdiagnoses and to the unnecessary prescribing of various drugs. Regardless of the specific causes or reasons for low testosterone it, will have one of three basic origins, which may be:
- Primary hypogonadism – originates from a problem in the testicles
- Secondary hypogonadism – originates from a problem in the hypothalamus or the pituitary gland, the two parts of the brain that signal the testicles to produce testosterone
- Tertiary hypogonadism – originates from another internal condition or from an external stimulus.
This specific origin or cause for hypogonadic symptoms determines which form of resolution (medical treatment) is used. Where the actual symptoms are concerned, although numerous and varied in severity from minor to debilitating, they are generally the same and can most commonly be characterized by the following symptoms:
- Reduction in lean body mass, and overall muscular strength
- Changes in cholesterol and lipid values
- Complications getting to and staying asleep throughout the night
- Problems with mental faculties such as loss of memory, trouble recalling facts or events, lack of mental clarity (concentration, focus, attention, etc.)
- Decreased body hair (both amount and thickness)
- Depressed or below normal hemoglobin levels, and possibly mild anemia
- Reduced energy levels, and lessened interest and participation in usual activities
- General malaise – a condition most characterized as general bodily weakness or discomfort, often marking the onset of a disease; a vague or unfocused feeling of mental uneasiness, lethargy, or discomfort
- Diminished capacity to burn body fat, resulting in more visceral (between and surrounding internal organs) and/or subcutaneous (below the skin) fat
- Decreased bone density, which increases the risk for breaks, fractures, and osteoporosis
- Changes in mood, which can manifest as irritability, depression, anger and fatigue
- Decreased libido (sexual desire), and diminished erectile quality and overall sexual performance
Diagnosing Low Testosterone
Probably the most prevalent initiator, or the factor which most often brings the condition low testosterone into question among adult males is the self-reporting of a perceived decrease in libido (sex drive), and what often amounts to a very noticeable reduction in sexual performance (prowess), i.e., erectile dysfunction – the chronic inability to achieve or maintain an erection for satisfactory intercourse. Although testosterone is largely responsible for regulating the libido and facilitating the male reproductive system, it also plays an important role in maintaining the body’s immune system and general balance for overall wellbeing. Consequently, secondary reasons for which men may seek medical care regarding suspected low testosterone include muscular weakness, depression, feelings of excessive fatigue, unexplained weight gain, etc. all of which are common symptoms of a decline in testosterone secretion.
So influential in maintaining balance within the male body, the low levels of testosterone (often cited as being below 300 ng/dL) or even less than optimal levels (700 – 1,100 ng/dl) can manifest as a variety of health-related conditions. For example, in addition to the earlier mentioned sexual dysfunctions, low testosterone can: decrease one’s ability to cope with traditional life stressors; reduce energy levels; disrupt sleep patterns; promote body fat gain; affect the brain’s faculties manifesting as emotional disturbances, mental instability, and memory complications; etc.
The multi-faceted diagnosis of low testosterone process typically begins with answering a standard self-reporting assessment tool called the ADAM (Androgen Deficiency in Aging Men) Questionnaire. This simple 10-question test is administered to quickly gauge if a patient is experiencing hypogonadic symptoms, and queries the tester in a variety of areas that are both directly and indirectly related to testosterone levels. By answering ‘yes’ or ‘no’ to each question, which addresses such areas as sleep, mood, stature, energy, sexuality, quality of life (work and play) ADAM is used as a preliminary tool for identifying low testosterone, and it’s questions are as follows:
|Do you have reduced libido (sex drive)?|
|Do you have a lack of energy?|
|Do you have a decrease in strength and endurance?|
|Have you lost height?|
|Have you noticed less enjoyment of life?|
|Are you sad and/or grumpy?|
|Are your erections less strong?|
|Have you noticed a recent deterioration in your ability to play sports?|
|Are you falling asleep after dinner?|
|Is your work performance suffering?|
Physicians also compile a history of symptoms by collecting other pertinent historical information that may not already be in the patient’s records. Among this information may be data on personal sexual, medical, and family medical histories.
Next up is the physical exam. Since testosterone is central to primary male development, a low testosterone diagnosis in men tends to cause either gradual or rapid changes within the body such as:
- Difficulty sleeping
- Changes in the amount of body hair
- Loss of peripheral vision often indicates the presence of a pituitary tumor
- Changes in the size of, or lumps in the breasts, testes, scrotum, and penis
- Increased body fat
- Reduction in muscle and/or bone mass
The physical exam typically contains a variety of additional questions about the patient’s current condition, which aren’t visible and are differentiated from both those within the ADAM Questionnaire and the past medical history questions. These questions center around traditional hypogonadic symptoms such as:
- Insulin resistance
- Increased breast tissue (gynecomastia)
- Recent bone fractures; loss of bone mass (osteoporosis)
- Loss of body, facial and pubic hair
- Poor concentration and/or memory
- Depression, anxiety, irritability
- Excessive sweating and night sweats
Finally, if enough evidence is gathered to suspect low testosterone, the physician will order a blood test. A good test measures (from two samples) the total testosterone level, and the actual measures for or calculated measures of both ‘free’ (available for function) testosterone and ‘bound’ (inactive) testosterone. The calculated version is often based on the levels of a liver synthesized glycoprotein known sex hormone-binding globulin (SHBG), which binds with and disables circulating androgens and estrogens.
Either based on the physician’s suspicions or in conjunction with the blood test sometimes other tests are used to identify non-hypogonadic underlying causes of low testosterone. Such tests commonly include:
- A magnetic resonance imaging (MRI), if the problem is thought to occur in the pituitary gland or hypothalamus in the brain.
- Prolactin level testing, as high prolactin levels can cause low testosterone. Prolactin is a hormone produced in the pituitary gland, so named because of its central role in lactation (producing breast milk), is a multi-faceted hormone found in males and females that is essential to immune system maintenance.
- Chromosome or genetic testing, if a genetic condition is suspected.
- Pituitary function testing, if the problem is suspected to occur in the pituitary gland.
- Semen analysis
- Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) testing. LH and FSH are hormones released by the pituitary gland that normally stimulate testosterone production in males.
Forms of Low Testosterone Therapy Medications
Although Testosterone Replacement Therapy (TRT) medication comes in a variety of forms, the basic treatment for hypogonadism can be one of numerous synthetic testosterone preparations each of which possess somewhat unique pros and cons.
Injectable testosterone solutions contain added esters, which primarily change the rate (or speed) of the medication’s absorption. Injectables are also popular because unlike orals, they are not first filtered by the liver, which promotes liver toxicity known as hepatotoxicity. The most prominently used injectable testosterone preparations are:
- Testosterone propionate, a short, fast-acting (2-3 days) ester
- Testosterone cypionate, a medium, longer-acting (7-8 days) ester
- Testosterone enanthate, a long-acting (7-8 days) ester
- Nebido, the very long-acting 2009 FDA approved testosterone undecanoate that actually permits medicinal dosing four times per year, i.e. every 3 months/90 days
Another form of testosterone replacement medication is that of the oral tablet. Orals are harsher on the liver than other preparations, and are generally taken daily or twice daily to guarantee that proper blood serum levels are maintained. Orals offer: greater privacy; vitamin-like convenience and ease of use; a viable option to needles for the injection squeamish; and the confidence of rapid and effective testosterone replacement.
Transdermals are a very popular non-invasive and unobtrusive form of testosterone delivery, the most popular of which include gels and patches. Transdermals combine many of the characteristics from other applications. Applied directly to and absorbed through the skin, transdermals access the capillaries and go straight into the bloodstream, which much like intramuscular injections do not promote significant hepatotoxicity.
The long-acting testosterone pellet is inserted subcutaneously (between skin layers), and can provide sustained testosterone release for 3 to 6 months. First developed in the 1940s, testosterone pellets are the oldest form of TRT. Not often used within the United States, pellet implantation is surgical, can be painful, and pellets have a tendency to extrude (be pushed out by pressure over time). Their very long duration of action makes reversibility difficult, and also makes pellets largely unsuitable for use in populations for whom adverse side effects are more common, such as women and elderly patients.
Transbuccal testosterone is one of the newest forms of TRT, and this tablet-like system adheres to gum tissue in the mouth (above the incisors), where testosterone is hydrated by the buccal mucosa and slowly absorbed. This form of TRT is transported from the buccal venous system directly into the superior vena cava – the large vein which returns blood to the heart from the head, neck and both upper limbs.
In short, the best time to seek medical care for low testosterone is as soon as the symptoms are recognized, or as one approaches the age at which hypogonadic symptoms usually to occur. However, whether an individual is reactive (acting in response to the problem) or proactive (acting before there’s a problem), testosterone therapy is equally successful. Providing several alternatives testosterone preparations to choose from, TRT use promises a positive outlook of rapid hypogonadic symptom reversal.
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- Low Testosterone and How it is Diagnosed
- by Chris Steidle, MD
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