“Doc, can you check me for low T? I saw an ad that made me think I could have it.”
I asked this 70-year-old about symptoms that could be related to low T, or low testosterone. He reported lowered sex drive, problems with sustaining erections, poor muscle mass and fatigue.
After getting multiple similar requests in the past couple years, I realized there was an active pharmaceutical advertising campaign to get men, particularly aging men, to be prescribed testosterone therapy. Let’s look at some of the issues about this.
It is true that testosterone decreases gradually with age. This has been called andropause or “MANopause.” This is more gradual and typically less symptomatic than female menopause. The drop in testosterone is not necessarily abnormal and many of the reported effects of “low T” may be related simply to the aging process.
No long-term studies have shown major health benefits or safety of replacement therapy in older men with borderline low testosterone. Indeed, we may have reason for concern since, in the absence of these studies, we might end up in a few years as we did with the results of the Women’s Health Initiative study. You may recall this study showed real long-term risks from female hormone replacement therapy in older women.
It is true that beneficial effects of testosterone can be seen on muscle mass, libido, bone density and sometimes improved erectile function. Cognitive changes, mood and skin health may also be improved. These are to some degree offset by concerns about the risks of extra testosterone on the prostate, blood count, cholesterol, blood pressure, heart failure, sleep apnea and acne. By the way, the cost of such replacement is around $400 a month.
A single low testosterone level needs to be checked out further as it may be caused by multiple factors besides simple aging and associated hypogonadism, or reduced testicular function. Many factors reduce testosterone: obesity, brain tumors in the pituitary gland, infections, diabetes, cirrhosis, HIV, kidney and other acute or chronic diseases, medications, chemotherapy, surgery, trauma, heavy use of alcohol or opiates and some genetic conditions.
Recognize that a single low testosterone level might not be accurate or definitive. Check it in the morning, especially for younger men, as it varies throughout the day. It is important to know that if you take testosterone inappropriately, it can shut down your own gonad production. If you stop the testosterone, it can go even lower than it was before. This may even require treatment with fertility drugs like clomiphene to restore testosterone production.
Replacement options include transdermal jells or patches or, the most physiological options, injections and pellets under the skin. Oral testosterone causes liver tumors and is no longer available except in preparations absorbable in the inner cheek.
Some key points regarding low testosterone are:
1) Be sure to get checked thoroughly for secondary causes of hypogonadism before beginning treatment with testosterone.
2) Overweight men can improve their testosterone through weight loss, diet, and exercise.
3) Don’t take testosterone if you have history of prostate problems or prostate cancer.
4) While taking testosterone, blood levels should be checked regularly to assure safe and effective dosing.
5) Erectile dysfunction doesn’t always require nor respond to testosterone replacement. Safer options may include L-arginine, DHEA, ginkgo, ginseng, horny goat weed or yohimbine, as well as medications like Viagra or Cialis. Psychological issues, medications, diabetes, drugs and alcohol must be considered as causes.
6) Loss of sex drive responds better to testosterone replacement than does erectile function, particularly if testosterone is lower than 300 ng/dl.