Testosterone is a hormone produced in the testicles that stimulate sperm production and libido in men. It also helps build muscle and bone mass. Testosterone stimulates your sex drive, and the ability to obtain and maintain an erection. Men may experience testosterone deficiency/hypogonadism, leading to sexual side effects. Testosterone replacement therapy when appropriately prescribed, can return your normal function.
Hypogonadism is syndrome defined as the failure of the testes to produce adequate levels of testosterone and sperm. Testosterone production peaks in early adulthood. By age 30, production begins to decline about 1% a year. A decrease in testosterone production is a normal consequence of aging. The good news is that the symptoms of hypogonadism are very common and easily treatable if low testosterone is truly the cause.
The term “low T” is often used interchangeably with hypogonadism or testosterone deficiency. However, it is important to understand that just because a man has low testosterone does not mean he needs testosterone replacement therapy to function normally. Only those men who have the symptoms of testosterone deficiency should undergo testosterone replacement therapy and make sure they understand the risks.
Low T Symptoms
- Low sex drive (aka low libido) may be one of the best indicators of having Low T.
- Difficulty getting and maintaining erections may be related to low testosterone.
- Shrunken and softer testicles may indicate you have Low T.
- Loss of body and facial hair.
- Increased fatigue, irritability, mood changes and depression.
- Reduced sexual sensation.
- Insomnia or other sleep disturbances, including sleep apnea. The treatment of sleep apnea can often treat the symptoms of “low T” without medication.
- Physical changes in increased body fat and reduced muscle mass.
Causes of Low T
Low T can be caused by chronic medical conditions, including:
- Liver and
- Kidney disease
Undescended testicles, pituitary disorders/tumors, physical damage to the testicles via trauma, surgery or infection, mumps and cancer treatment, HIV/AIDS, some medications and inflammatory diseases can cause hypogonadism or testosterone deficiency. You will be checked to rule out these causes.
Diagnosis of Low T
To diagnose low T, your doctor will take a medical history and perform an exam. Your symptoms will be assessed by a questionnaire and he will evaluate the amount and distribution of your body hair. You will have standard blood tests to determine your testosterone levels.
With one sample, your blood will be tested for total testosterone and free testosterone. Free testosterone is that which flows freely in your bloodstream. Additional blood tests will be ordered to rule out other causes of your symptoms, including pituitary hormones, estrogen levels, thyroid, and liver function tests. The results of these tests will be correlated with your symptoms. Some symptoms of osteoporosis and those associated with sleep apnea will need further investigation with scans and other testing.
Testosterone Replacement Therapy
Before treatment, your doctor will discuss with you the goals, risks and potential benefits of testosterone replacement therapy. Once your diagnosis is confirmed, there are various therapies to treat “low T.” Low T is easily treated with injections, patches, topical gels/creams, nasal solutions and pellets implanted under the skin that release testosterone into your system.
Topical gels and creams usually last for 24 hours and are most likely to mimic the normal rhythm of natural testosterone. Topicals have the risk of rash and transfer to your partner or children. Several brands have convenient ways to apply for the medication and insurance often covers them.
Testosterone injections can be short-acting, lasting 4-7 days, or depot formulations, which last about 3 months and require 4-5 injections. Injection-related testosterone levels usually peak after 2-4 days then drop. There is a concern that testosterone levels that rise very high and go unchecked can increase the risk of blood counts above safe levels and cause blood clots to develop. Some men can have a “roller coaster” effect if they are dosed too infrequently. Testosterone levels that plummet lower than baseline prior to getting the next injection can affect mood, stability, and sexual activity. This occurs because testosterone replacement suppresses your normal testosterone production so you may become dependent on the medication.
Small testosterone pellets can be implanted under the skin, in the office, after the skin is numbed with an anesthetic. They slowly release testosterone over the course of 3-6 months. Testosterone levels do not peak but reach a steady plateau, so men often experience a “more” normal T rather than the high one may experience with injections. Side effects may include bruising or hematoma at the implantation site and temporary leg swelling. Small studies have suggested there is a lower risk of blood clot formation with pellets, possibly because testosterone levels usually do not get very high.
Testosterone supplementation can result in impairment of sperm production and should not be used when future fertility is desired. If you want children within the next few years, do not use testosterone unless under the supervision of a male reproductive specialist. Alternative drugs are available for men in their reproductive years including aromatase inhibitors, hCG, and SERMs or selective estrogen receptor modulators. These therapies improve testosterone levels and preserve and enhance sperm formation.
Benefits of Testosterone Replacement Therapy
Testosterone Replacement Therapy provides many benefits, including:
- Improved sex drive
- Improved erectile function, erections, ejaculations and sexual satisfaction
- Improved bone mineral density
- An increase in lean body mass
- Improvement in energy, and mood
- Improved glycemic control in men with diabetes
- Decrease in fat mass
- Improved triglycerides and total cholesterol
Once you begin testosterone replacement therapy, your doctor will regularly monitor your response. If you fail to experience symptomatic relief after 3-6 months, it may be discontinued. If you do experience improvement in symptoms, you will be monitored to assure continued benefits. Your blood counts, liver function tests, prostate-specific antigen (PSA) as well as testosterone levels will be checked at least at 6-month intervals.
Contraindications to Testosterone Replacement Therapy
Men with untreated sleep apnea and untreated severe congestive heart failure should not undergo testosterone replacement therapy. Men with preexisting heart disease should proceed with caution when considering testosterone replacement. Studies show conflicting information on whether testosterone replacement therapy leads to increased risk of heart attacks in this population. Nevertheless, men with heart disease should proceed with caution when making the decision to start taking testosterone.
Potential Side Effects of Testosterone Replacement Therapy
As with any drug, there are some side effects from testosterone replacement therapy including acne, oily skin, fluid retention, and breast enlargement. Talk to your doctor to find out if testosterone replacement therapy is right for you. A serious risk of blood clots, heart attacks, and strokes can occur. However, the side effects, besides blood clots, currently lack definitive evidence.
Our team at Erlanger Urology has extensive experience in male reproductive endocrinology and hormone replacement. We believe that testosterone replacement therapy can positively affect men and get them back to a more fulfilling lifestyle when given for the right reasons. On the other hand, plenty of men who have low T levels may not require replacement and can have serious side effects if replacement is given for the wrong reasons or in an inappropriate manner. We care about improving your lifestyle and will help guide you through the testosterone replacement therapy process. We practice evidence-based medicine and patient-centered care. To receive the individualized care you need, contact us today.
Anand Shridharani, MD, is a board-certified, fellowship-trained specialist in male reproductive and prosthetic urology with Erlanger Urology in Chattanooga, TN. His practice offers comprehensive men’s reproductive and sexual health services including comprehensive management of the infertile male, reproductive microsurgery including vasectomy reversal, urologic cancer survivorship, and penile/urethral reconstruction.