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