Many men face symptoms of low testosterone (low T) throughout life, such as low energy and low sex drive.

There has been a lot of discussion and research of menopause in women, however, not until recently has there been a spotlight on low Testosterone (low T) in men. Some have called this “Andropause”. Low testosterone affects about 40% of men over the age of 45. As men age, their levels of testosterone may decrease. Increasingly, people are mentally, physically, and sexually active much later in life than our parents or grandparents. At the Austin Urology Institute we do an extensive work-up to find the source of your symptoms and help you feel better.

Low Testosterone Information

What is testosterone?

Testosterone or “T” is a hormone, which 95% is made by the testicles and 5% by the adrenal glands. Testosterone has predominantly been regarded as a sex hormone; having said that, it also has important biologic effects on metabolism, bone, muscle integrity, the cardiovascular system, and the brain. T is released in a circadian rhythm (your body’s internal clock) that peaks between 6am-8am, and drops to its lowest between 6-8pm. Interestingly, overall T levels are the highest in summer/late autumn, and lowest in the winter/early spring.

What is low testosterone?

What exactly is a Low T level? Check on the internet, or any lab guideline, and you’ll see a significant range of what is normal. Interestingly, guidelines vary between international and national societies. Normal ranges used in clinical labs are based on normal ranges of healthy young men. Ranges can also vary between countries and labs. We like to see levels between 400-600 as a normal range for most men. For example, we see men with a T level in the high 200s that are not experiencing any symptoms. We find that different men will need a different T level to feel well. We also see many men who have signs and symptoms of low T, but might find their T in the 400-500 range. This reinforces the idea that low T may not be the only factor in low energy, libido, and other signs of low T. I like using the analogy that although a 4-cylinder engine might be good for a small Toyota, a Ford Truck may very well need a V-8 to do its job.

Symptoms

  • Low libido or sex drive
  • Fatigue / Lack of energy
  • Decreased focus or concentration
  • Erectile Dysfunction
  • Depressed mood
  • Decreased strength or endurance

Causes

Testosterone levels tend to decrease with age. After the age of 30, men may start noticing the symptoms of low T. Causes of Low T may also originate higher up on the hormonal axis. Certain hormones secreted in the pituitary gland of the brain drive testosterone production. They are FSH (follicle-stimulating hormone), and LH (luteinizing hormone), and prolactin. When these hormones are abnormal, T levels may be decreased. Other less common causes include increased estrogen levels, trauma to the testicles, and anabolic steroid use.

Although many people may find that Low T is their primary issue, some people will still find that other issues, some medical, and some non-medical (work or life stressors) may be a significant source of their symptoms. Low T can also result in a loss of self-esteem and confidence. It is also important to know that a fall in libido or sex drive can also be commonly associated with medical conditions, such as depression, anxiety, and other disease states.

Diagnosis

We perform a thorough evaluation on each patient that exhibits symptoms of low testosterone. Since symptoms can be caused by other medical conditions, this comprehensive lab panel covers for other reasons you may be experiencing low libido, fatigue, and erectile dysfunction. Screening includes low testosterone, low thyroid hormones, increased estradiol, diabetes, high cholesterol, low B 12 levels, and anemia. These labs are done with a blood test. Sleep disorders, such as sleep apnea are also evaluated. If during your history, you indicate to us that sleeping well is a problem, we may send you to get a sleep study done, as this could be a contributing source of fatigue.

Treatment

Treatment for low testosterone is based on symptoms and correlating labs. Treatment is delivered through testosterone supplementation, or by increasing the hormones that drive testosterone production.

Clomid

This is an oral medication, typically used to treat male and female infertility by increasing hormones in the pituitary gland that drive testosterone and sperm production. This may be used for patients who want to maintain fertility. Exogenous testosterone supplementation (creams, injections, etc.) can affect your testicles’ own production of testosterone, and thereby compromise sperm production and fertility. Clomid is an oral pill daily every morning. We typically do a 3 month trial followed by a repeat testosterone lab to evaluate how you are doing on the medication. It is also used to increase sperm counts in those undergoing fertility treatment.

Testosterone Injections

Testosterone injections are done on a weekly basis, and are injected into the muscle. The dose is 0.5ml, however we take your baseline testosterone level at diagnosis into consideration. Testosterone levels tend to increase quicker and at a higher number than the topical treatments or Clomid. Because of this, patients may notice symptoms improving in 1-2 months vs. 3 months.

The first four injections are done at our clinic. This allows us to monitor your symptoms and instruct you on eventually doing these injections at home. Once you have completed the 4 weekly injections at our clinic, you may continue them on your own at home. You may have some mild muscle soreness which decreases with time.

Topical Gels/Creams

The gel is simply applied in the morning after showering, depending on the brand, either on the chest, the underarms, or upper thigh area. Usually we will start you off at one pump per side. The gel takes a few minutes to dry. The risk of transferring to others decreases after 2 hours of application.

There are brand name gels and also generic creams available. A trial of gel/cream is started for 3 months, after which we check your testosterone levels and evaluate improvement in symptoms.

Risks of testosterone supplementation

Potential risks of an increased testosterone level include cardiac events such as increasing blood pressure, heart attacks, and stroke. While there are benefits to testosterone treatment, there are serious risks as well. We evaluate your initial labs thoroughly to ensure that you are receiving treatment for true hypogonadism (low testosterone). Once treatment is initiated, we follow your testosterone levels closely (every 3-6 months) to determine if you are within a normal/safe range. If you experience any side effects of high testosterone, such as increase in blood pressure, irritability, agitation, or aggression notify your doctor.

Testosterone Facts

  • By the age of 40, T levels begin to slowly fall, on the order of 1-2% per year.
  • T is released in a circadian rhythm that peaks between 6-8am, and drops to its lowest between 6-8pm. Interestingly, overall T levels are the highest in summer/late autumn, and lowest in the winter/early spring.
  • Testosterone has predominantly been regarded as a sex hormone; having said that, it also has important biologic effects on metabolism, bone, muscle integrity, the cardiovascular system, and the brain.
  • Low T can be associated with a reduction in strength of erections and loss of early morning erections. Vascular disease, hypertension, different medications for the heart and or blood pressure can all cause ED in addition to coexisting with low T.
  • Low T and Osteoporosis have been linked. Approximately 15% of men by the age of 50 may be at risk for developing bone fractures later in life. This can increase to 25% by the age of 60. In the US, men account for approximately 150,000 hip fractures a year.
  • Fatigue can be a common symptom of hypogonadism. As the day progresses, you can feel more and more tired and lethargic. Additionally, there can be a reduced ability to undertake physical tasks that require endurance such as gardening, or distance walking.
  • Mood disturbance is another important symptom. Depression, irritable behavior, poor concentration, and mood swings can be seen.
  • T is critical in maintaining normal penile architecture and vascular flow. Restoration ofnormal T levels can convert over half of patients who initially did not respond to Viagra, into patients that respond well to Viagra.
  • T supplementation does not cause prostate cancer. However, if prostate cancer is present, T supplementation can cause the cancer to accelerate. Routine monitoring of PSA and prostate cancer screening is recommended. Notify Dr. Shaw if you or a family member has a history of prostate cancer.

T supplementation, when used for over 5-6 years, decreases your body’s ability to make
testosterone on its own.

  • The hormones FSH and LH in the brain eventually slow down, and stop driving testosterone production by the testicles, since the body is receiving supplementation from an outside source.
  • FSH and LH are also responsible for sperm production, and need to be at appropriate levels in men who are planning to conceive soon or in the future.
  • For men who wish to maintain fertility, we recommend using the medication,Clomid described earlier. Clomid provides the body testosterone by increasing levels of FSH and LH. This in turn also improves fertility. These men will likely be placed on a short 3 month trial of T supplementation to see if levels increase. If response to the gels is good, they will be switched to Clomid, which may be used long-term.
  • In men who no longer want children, long term T supplementation is not a problem.

What else can I do to improve my symptoms?

Many times your testosterone levels may come back at a normal-high level, along with normal blood work that we’ve used to rule out any other medical conditions contributing to your symptoms. This indicates that testosterone is not likely the culprit responsible for how you are feeling. See below to find out other ways you can improve your symptoms.

  • Diet – Maintaining a healthy diet is simple and good way to stay alert and energized.We recommend reducing processed foods, salt and sugar intake, fatty food, and simple carbohydrates (sugar, enriched white flour, etc). Replace these foods with fruits, vegetables, fish, lean poultry, and complex carbohydrates (whole grain, oatmeal, beans, legumes, lentils, etc.). Losing fat through diet and exercise can also help increase testosterone levels naturally.
  • Exercise – Add an exercise regimen at least three times a week, particularly cardiovascular exercise. Jogging is a great way to start. Cardiovascular exercise gets your heart pumping and your blood flowing which can help in many areas such as improvement in energy levels, sleep, weight loss, decreasing risk for diabetes, high cholesterol, and high blood pressure. Exercise can also improve testosterone levels as well as erectile dysfunction.
  • Sleep – Lack of sleep is most important when it comes to decreased energy, but can also be responsible for erectile function. You should be getting about 8 hours of uninterrupted sleep per night. If you have sleep apnea or snore at night, we recommend getting a sleep study done. Other ways to improve sleep include melatonin (over the counter), or prescription sleep medications. You can talk to your primary care doctor about further options as well.
  • Stress – Stress can easily mimic many symptoms of low testosterone such as fatigue, low libido, erectile dysfunction, and depression. Acknowledging sources of stress in your life is a good first step. Ways to manage stress are different for each patient and each situation. Find out what works best for you, whether it is making time for yourself or speaking to someone professionally.

Low Testosterone Questionnaire

(3+ Yes answers may suggest low T)

  • 1.Do you have a decrease in libido/sex drive?
  • 2.Do you have a lack of energy?
  • 3 Do you have a decrease in strength/endurance?
  • 4 Have you lost height?
  • 5 Have you noticed a decreased enjoyment of life?
  • 6 Are you sad or grumpy more often?
  • 7 Are your erections less strong?
  • 8 Have you noticed a recent deterioration in your ability to play sports or other activities?
  • 9 Are you falling asleep after dinner?
  • 10 Has there been a recent deterioration in your work performance?