Testosterone is the male sex hormone that is made in the testicles.
Testosterone hormone levels are important to normal male sexual development and
functions.
During
puberty (in the teen years), testosterone helps boys develop male features like
body and facial hair, deeper voice, and muscle strength. Men need testosterone
to make sperm. Testosterone levels generally decrease with age, so older men
tend to have low blood testosterone levels.
Some
men have low testosterone levels. This is called Testosterone Deficiency
Syndrome (TD) or Low Testosterone (Low-T). Deficiency means that the body does
not have enough of a needed substance. Syndrome is a group of symptoms that,
together, suggest a disease or health condition.
The
American Urology Association (AUA) identifies low blood testosterone (Low-T) as
less than 300 nanograms per deciliter (ng/dL). These symptoms or conditions may
accompany Low-T:
- Low sex
drive
- Fatigue
- Reduced lean
muscle mass
- Irritability
- Erectile dysfunction
- Depression
- There are many
other possible reasons for these symptoms, such as: opioid use, some
congenital conditions (medical conditions you are born with), loss of or
harm to the testicles, diabetes, and obesity (being overweight). See your
doctor if you have any of these symptoms.
Why Testosterone Therapy (TT)?
You
may need testosterone therapy (TT) if you have Low-T. Both the FDA and the AUA
suggest that TT be used to treat conditions you are born with, such as
Klinefelter syndrome.
You
also may need TT if you harm or lose your testicles. If your testicles are
removed because of a sickness such as cancer, you may need TT. Most men with
Low-T (no matter what the cause) will be treated if they have both symptoms of
Low-T and blood tests showing Low-T levels. Talk with your doctor if you feel
that you may need TT.
TT may
help you but it may have adverse (harmful) results. (See discussion of these
side effects below.) The Federal Drug Administration (FDA) has said that
testosterone drug labels should state that there is a risk for heart disease
and stroke for some men using testosterone products. All men should be checked
for heart disease and stroke before, and periodically while on, TT. The AUA
however, on careful review of evidence-based peer review literature, has stated
that there is no strong evidence that TT either increases or decreases the risk
of cardiovascular events.
The
FDA also was concerned when they found that men were being treated for Low-T
due only to aging. There is ongoing research to determine more about TT in
aging men. Your doctor will talk with you about the benefits and risks of TT
and carefully consider how to treat your symptoms.
How Common is Low Testosterone in Men?
It is
hard to know how many men among us have TD, although data suggest that overall
about 2.1% (about 2 men in every 100) may have TD. As few as 1% of younger men
may have TD, while as many as 50% of men over 80 years old may have TD. People
who study the condition often use different cut-off points for the numbers, so
you may hear different numbers being stated.
TD is
more common in men who have diabetes or who are overweight. In one research
study, 30% of overweight men had Low-T, compared to only 6.4% of those with
normal weight. The same study found diabetes to be a risk factor for TD. In
another study, 24.5% of men with diabetes had Low-T, compared to 12.6% of those
without diabetes.
There
are many signs and symptoms of Low Testosterone. Some are more closely related
to Low-T levels (specific signs and symptoms). Others may not necessarily be
linked (non-specific signs and symptoms). Your doctor will help you make sense
of your own situation.
Specific Signs/Symptoms of Testosterone Deficiency (TD)
Specific
symptoms are those more likely or directly linked to TD such as:
- Reduced sex
drive
- Reduced erectile
function
- Loss of body
hair
- Less beard
growth
- Loss of lean
muscle mass
- Feeling very
tired all the time (fatigue)
- Obesity (being
overweight)
- Symptoms of
depression
Non-specific Signs/Symptoms of Testosterone Deficiency (TD)
Non-specific
symptoms are those that may or may not be linked to TD such as:
- Lower energy
level, endurance and physical strength
- Poor
memory
- Difficulty with
finding words to say
- Poor focus
- Not doing well
at work
Having
any one of the specific or non-specific symptoms may not mean that you have TD.
But if you have a mix of symptoms, for instance, if you start to feel very tired
and sad over a period of time and this is a change for you, you may want to
check for TD.
Low
sexual desire alone may not mean that you have TD. But if you have a
combination of low sexual desire, reduced erectile function, and feelings of
sadness and tiredness, you should talk to your doctor.
Some
persons are born with conditions that cause Testosterone Deficiency (TD)
such as:
- Klinefelter
syndrome
- Noonan syndrome
- Ambiguous
genitalia (when the sex organs develop in ways that are not typical
looking)
Some
men may develop Low-T because of conditions like these:
- Damage to
testicles by accident
- Removal of
testicles because of cancer
- Chemotherapy or
radiation
- Pituitary gland
disease leading to hormone deficiency
- Infection
- Autoimmune
disease (when the body makes antibodies that attack its own cells)
Basically,
if your testicles keep making less testosterone than normal, your blood levels
of testosterone will fall. Many men who develop TD have Low-T levels linked to:
- Aging
- Obesity
- Metabolic
syndrome (high blood pressure, high blood sugar, unhealthy cholesterol
levels, and belly fat)
- Use of
medications such as antidepressants and narcotic pain medications
Men
with certain health problems also tend to have low testosterone. Some of these
are:
- HIV (about 30
out of 100 also have low testosterone)
- AIDS (about 50
out of 100 also have low testosterone)
Although
many symptoms may be tied to Low Testosterone (Low-T), total blood testosterone
level is the most important measure of testosterone deficiency. To make a
diagnosis, your doctor will use other specific signs and symptoms in addition
to your testosterone blood level.
At
your medical visit, your health history will be taken, and the doctor will do
an exam and look for some of the signs and symptoms mentioned in this article.
Health History
Your
doctor may ask you about:
- Headache, visual
field change (possible symptoms of brain mass such as a pituitary
tumor)
- How you
developed at puberty
- History of head
trauma
- Cranial (head)
surgery/brain tumor or cranial irradiation
- Anosmia (loss of
ability to smell)
- History of
infection in your testicles
- Injury to your
testicles
- Mumps after
puberty
- Past or present
use of anabolic steroids
- Use of
opiates
- Use of
glucocorticoids (medicines, such as cortisone, used to treat
inflammation)
- History of
chemotherapy or irradiation
- Family history
of diseases linked to Low-T
- History of
stroke or heart attack
- History of
unexplained anemia
Physical Examination
Your
doctor will check for the following:
- BMI or waist
circumference for obesity
- Metabolic
syndrome. These are symptoms (seen together) of increased blood pressure,
high blood sugar, excess body fat around the waist, and abnormal
cholesterol or triglyceride levels
- Hair pattern,
amount, and location
- Gynecomastia
(enlarged breasts)
- Whether
testicles are present and their size
- Prostate size
and any abnormalities
Testing
Your
doctor may order these blood tests:
- Total
testosterone level. This test should be done at two different times
on samples taken before noon. Testosterone levels are lower later in the
day. If you are ill, the doctor will wait until you are not sick because
your illness may cause a false result.
- Luteinizing
hormone (LH). This test is done to help find the cause of a Low-T
level. This hormone controls how you make testosterone. Abnormal levels
may mean a pituitary gland problem.
- Blood prolactin
level. If your prolactin level is high, your doctor may repeat the
blood test to make sure there is no error. High prolactin levels also may
be a sign of pituitary problems or tumors.
- Blood hemoglobin
or Hgb. Before doing this test, your doctor will look for other
reasons for low Hgb such as climate level (like climate altitude), sleep
apnea, or tobacco smoking.
The
following also may be done to help with further diagnosis:
- Follicle
stimulating hormone (FSH). This test is to check for sperm-making
function if you want to have children. You may also need to have semen
tests. These tests will be done before any hormone therapy.
- Estradiol
hormone test is done if there are breast symptoms.
- HbA1C blood
test may be done for diabetes.
- MRI ( magnetic resonance imaging) of the
pituitary gland
- Bone density tests.
- Karyotype (Chromosome
tests).
You
may hear about free testosterone or bioavailable tests for testosterone. These
are not the same as total testosterone level tests. Ask your doctor about the
differences and if you need these tests.
In
recent years, the media has reported more about Testosterone Therapy (TT), and
more men between the ages of 40 and 64 have been tested and given TT. Some men
with certain symptoms may even want TT without being tested. This action may
not be safe or helpful for them. Total testosterone level should always be
tested before any TT.
The
AUA recommends that TT be prescribed only to men who meet the clinical and
laboratory definition of testosterone deficiency (Testosterone level of less
than 300 ng/dL). Here are some of the things you will need to know about TT:
- Your doctor will
likely measure your testosterone level if you have these conditions:
- Unexplained
anemia
- Diabetes
- Bone density
loss
- Low-trauma bone
fracture
- Radiation to
your testicles
- HIV/AIDS
positive test results
- Chronic
narcotic use
- History of
infertility
- Pituitary gland
disorders
- Even if you do
not have specific signs and symptoms, your doctor may test your total
testosterone level for these conditions:
- Insulin
resistance
- History of
chemotherapy
- History of
using corticosteroid medicines
- Health changes
such as losing weight and getting more physical activity will likely raise
your testosterone levels.
- Your doctor will
want to check your hemoglobin/hematocrit (Hgb/Hct) levels while you are on
TT. This blood test will help check for thickening of the blood.
- Blood thickening
may cause blood clots. Your doctor may do Hgb/Hct levels two to six weeks
after you start TT and every six to twelve months after that test.
- If you are at
risk for heart disease, your doctor will follow you more closely when you
are on TT. It also is important to make health changes to decrease the
chances for heart and blood vessel disease.
- Your doctor will
treat your Low-T level to raise it above 300ng/dl but the exact level may
vary.
- Your doctor will
watch you for signs and symptoms of improvement. Any changes will likely
appear within three to six months of treatment.
- If your total
testosterone blood level returns to normal and you still have symptoms, it
is likely that there are other reasons for your symptoms. Your doctor may
stop TT and try to find out what else might be the problem.
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