By Wasim Haque, MD
Testosterone is the male sex hormone and controls normal sex drive and sperm production. Testosterone also helps maintain bone strength, muscle strength, red blood cell production and physical stamina in men.
As you age, your Testosterone level (T Level) gradually declines (~1% per year after age 30-40). It is important to differentiate between the normal age-related decline in T levels and abnormal drop due to a disease (called “hypogonadism” or sometimes referred to as “Low T”). Low T may affect your sexual function and physical well-being.
There are several FDA-approved testosterone treatments which may increase T levels and may help improve Low T symptoms such as low libido, erectile dysfunction and reduced stamina and energy levels.
T treatment should be started after a careful examination and testing by an experienced physician or provider. Sometimes Low T can be from serious underlying conditions such a pituitary tumor, sleep apnea and your physician may order additional testing depending on your symptoms and a thorough physical examination.
If you are noted to have Low T levels, your doctor will probably repeat the test because blood T levels can be pulsatile (variable throughout the day) and therefore the diagnosis should be confirmed before treatment is initiated. In addition if you have underlying conditions that can cause temporary Low T levels (e.g. pain or use of narcotic pain medications or sleep apnea), once the condition improves, these levels will become normal.
Diagnosis & Misdiagnosis
Based on expert guidelines, Low T (hypogonadism) occurs when the blood testosterone levels (drawn before 10 a.m.) are less than 300-325 ng/dL or/and blood “free testosterone” level (a more accurate test, if a man is overweight or is older than age 65) is less than 55-65 pg/mL. The Low T level should be rechecked at least one more time, before a diagnosis of hypogonadism is confirmed.
Although advertised as an anti-aging formula that improves alertness, mood and stamina, the health benefits of T therapy are not always clear and the “performance-benefits” (sexual and general vitality) are often short-lived (unless large and “risky” doses are administered). Unless monitored carefully, T therapy can increase blood pressure, thickness of blood and worsen lipid (fat) levels.
Some older men treated with T therapy in clinical studies, carried out by the National Institute of Health (NIH) experienced increased risk of developing heart problems and strokes.
If you have Low T levels, T therapy can improve your quality of life by enhancing your sexual function, improving your mood, alertness, stamina and motivation. If you combine this with an improved diet and increased exercise, it may help shed off some of the belly fat, build muscle mass and improve blood pressure, blood sugar and strengthen your bones. Usually you will start feeling better in 3 or 4 weeks. You should be checked every 3 months in the first year and then every 6 months in most cases. Your prostate gland should be checked annually because in some cases, T therapy may accelerate the normal age related increase in prostate size.
If your Low T level is caused by an underlying condition (such as obesity, sleep apnea, severe pain or serious illness), treating that condition may help improve Low T level. Healthy lifestyle and weight loss may reverse Low T levels in some cases. Starting high doses of T therapy (particularly injections) too early in such cases, can convert a potentially “reversible situation” into a “permanent condition.” This is called the testosterone trap. This “trap” occurs because, when T is given to a patient, his body stops making its own testosterone (suppression of testosterone production by downgrading body’s pituitary to testes communication that normally regulates natural testosterone production in a pulsatile manner). The problem is less likely to occur if the T level is kept in the mid-normal range (usually recommended range is between a serum total testosterone level of 400-700 ng/dL or a free testosterone level of between 65 and 150 pg/mL).
There are other ways to reduce the risk of this testosterone trap. The nasal testosterone preparation, Natesto, may have an advantage over other preparations of testosterone because it is short-acting and is administered three times every day. The blood T levels in patients who take Natesto vary through the day, like that in normal individuals. The risk of testosterone trap is therefore lower. If the older T preparations (such as injections or gels) are used, the risk of testosterone trap can also be lowered by using smaller doses or concomitant and intermittent use of a hormone called HcG (a hormone similar to the pituitary hormone called LH which normally regulates testosterone production by the testes) or by taking a tablet called Clomiphene, a pill which also stimulates the pituitary gland to increase signal directing the body to make more testosterone of its own. These steps may also reduce the risk of side effects of T therapy in most cases.
The number of men using T therapy in the United States has increased dramatically in recent years. Taking this hormone to reverse aging and raising blood levels to “youth levels” can be dangerous and is not advisable. On the other hand, treatment of legitimately Low T levels can improve quality of life dramatically. It is however important to understand that like any other medication, there are risks and benefits of T therapy. You should undergo a thorough evaluation by your physician before you start T therapy. Only after that should you begin T therapy so you may get maximum benefits of such therapy and at the same time reduce any potential risks.
Dr. Wasim Haque is a Board Certified Endocrinologist who has been serving this community since 2004. He is a Principle Investigator with the Prime Revival Institute – a clinical research organization which helps bring latest clinical research trials to local communities.