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What is ‘Low-T’ & how do I know if I am?

What is ‘Low-T’ & how do I know if I am?

Dear Dr. Freier,
I am 45 years old, in good health, but I don’t have the energy that I once did.  I often feel worn out and sometimes I am a little depressed… and I am struggling to keep my weight under control.  I have been reading on-line about Testosterone, and I am wondering if I perhaps I have low testosterone levels which is causing me these problems.  How do I know if I have low testosterone and how do I increase it if I do?

Jose M.
Estero, FL

Thank you for your question Jose. Low testosterone is a syndrome which affects millions of men all over the world and rarely gets the attention it deserves. Because it commonly affects men in middle age, it is often dismissed by doctors as part of the normal aging process and not life threatening. Unfortunately, however, low testosterone levels can severely decrease a man’s quality of life.

Low testosterone, also known as male hypogonadism, testicular hypofunction or by the slang “Low-T”, is a condition in which the testicles do not produce enough testosterone. Testosterone is the hormone that plays several key roles in masculine growth and development during puberty.  Testosterone also contributes to men’s sexual function, weight management, and energy level during adulthood.  Men can be born with hypogonadism, or it can develop later in life. Besides being age related, it can often be due to injury or infection in younger age groups.  The effect of hypogonadism, as well as what can be done about it, greatly depends on the cause and at what point in your life it occurs.

During fetal development, if the body doesn't produce enough testosterone there may be impaired growth of the external sex organs resulting in a smaller penis or testicles.  Depending on when hypogonadism develops and how much testosterone is present, a child who is genetically male may be born with female genitals, ambiguous genitals (genitals that are neither clearly male nor clearly female), or underdeveloped male genitals.

If hypogonadism develops prior to or during puberty it may delay puberty or cause incomplete or complete lack of normal development.  Symptoms usually include decreased muscle mass, no deepening of the voice, decreased growth of body hair, decreased growth of the penis and testicles, excessive growth of the arms and legs in relation to the trunk, and development of breast tissue, which is known as gynecomastia.

In adults, hypogonadism may alter certain masculine physical and mental characteristics, as well as impair normal reproductive function.  Signs and symptoms may include erectile dysfunction, infertility, decrease in beard and body hair growth, decrease in muscle mass, gynecomastia, and loss of bone mass (osteoporosis).

Hypogonadism can also cause mental and emotional changes in adult men.  As testosterone decreases, some men may experience symptoms similar to those of menopause in women, such as fatigue, decreased stamina, weight gain, depression, difficulty sleeping, decreased sex drive, difficulty concentrating, and even hot flashes.

There are two (2) basic types of hypogonadism (Low-T), Primary and Secondary.  Primary hypogonadism, also known as primary testicular failure, originates from a problem located in the testicles.  Secondary hypogonadism describes a problem that originates in the hypothalamus or the pituitary gland.  These are parts of the brain that signal the testicles to produce testosterone.  The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone (LH).  Luteinizing hormone then signals the testicles to produce testosterone.  Either type of hypogonadism may be caused by an inherited trait (congenital) or something that happened later in life, such as an injury or an infection (acquired).  At times, primary and secondary hypogonadism can even occur together.

Primary hypogonadism can be caused by several conditions, such as: 1) Klinefelter syndrome.  This condition results from a congenital abnormality of the sex chromosomes, X and Y.  A male normally has one X and one Y chromosome.  In Klinefelter syndrome, however, two or more X chromosomes are present in addition to the one Y chromosome.  The Y chromosome contains the genetic material that determines the sex of a child and related development.  The extra X chromosome that occurs in Klinefelter syndrome causes abnormal development of the testicles, which in turn results in underproduction of testosterone. 2) Undescended testicles.  Before birth, the testicles develop inside the abdomen and normally move down into their permanent place in the scrotum. Sometimes one or both of the testicles may not be descended at birth.  This condition often corrects itself within the first few years of life without treatment.  If not corrected in early childhood, however, it may lead to malfunction of the testicles and reduced production of testosterone.  3) Mumps orchitis.  If a mumps infection involves the testicles in addition to the salivary glands during adolescence or adulthood, long-term testicular damage may occur.  This may affect normal testicular function and testosterone production.  4) Hemochromatosis.  Too much iron in the blood can cause testicular failure or pituitary gland dysfunction, affecting testosterone production.  5) Injury to the testicles.  Because they're situated outside the abdomen, the testicles are prone to injury.  Damage to normally developed testicles can cause hypogonadism. Damage to only one of the testicles may not completely impair testosterone production.  6) Cancer treatment.  Lastly, chemotherapy or radiation therapy for the treatment of cancer can interfere with testosterone and sperm production.  Luckily, the effects of both treatments are often temporary, but permanent infertility may still occur.

Secondary hypogonadism can also be caused by several conditions, the difference in secondary hypogonadism is that the testicles are normal but function improperly due to a problem with the pituitary or hypothalamus.  These conditions including: 1) Kallmann syndrome.  Abnormal development of the hypothalamus, the area of the brain that controls the secretion of pituitary hormones, can cause hypogonadism.  This abnormality is also associated with impaired development of the ability to smell (anosmia) as well as red/green color blindness.  2) Pituitary disorders.  An abnormality in the pituitary gland can impair the release of hormones from the pituitary gland to the testicles, affecting normal testosterone production.  A pituitary tumor or other type of brain tumor located near the pituitary gland may cause testosterone or other hormone deficiencies.  Also, the treatment for a brain tumor, such as surgery or radiation therapy, may impair pituitary function and cause hypogonadism.  3) Inflammatory disease.  Certain inflammatory diseases, such as sarcoidosis, histiocytosis and tuberculosis, involve the hypothalamus and pituitary gland and can affect testosterone production.  4) HIV/AIDS can cause low levels of testosterone by affecting the hypothalamus, the pituitary, and the testes.  5) Medications.  The use of certain drugs, such as opiate pain medications and some hormones, can affect testosterone production.  6) Obesity.  Being significantly overweight at any age will increase estrogen production and can lower testosterone levels.  7) Normal aging.  Older men generally have lower testosterone levels than younger men do.  As men age, there's a slow but steady decrease in testosterone production. Testosterone levels usually peak around 17 years of age and starts to decrease each year after age 30.  In some men this can be substantial.  The rate at which testosterone declines varies greatly among men.  As many as 39 percent of men older than 75 have a testosterone levels that negatively impacts their quality of life.  8) Concurrent illness.  The reproductive system can temporarily shut down due to the physical stress, illness, or surgery, as well as during significant emotional stress.  This is a result of diminished signals from the hypothalamus and usually resolves with successful treatment of the underlying condition.

In order to diagnose hypogonadism your doctor should conduct a physical exam during which he or she will note whether your sexual development, such as your pubic hair, muscle mass and size of your testes, is consistent with your age.  Your doctor will also test your blood level of testosterone if you have any of the signs or symptoms of hypogonadism (Low-T).

Early detection in boys can help prevent problems from delayed puberty. Early diagnosis and treatment in men offer better protection against erectile dysfunction, osteoporosis, and other related conditions.

Doctors base a diagnosis of hypogonadism on symptoms and results of blood tests that measure testosterone levels.  Because peak testosterone levels vary in individuals and are rarely checked in early adulthood there is no true reference range.  Insurance companies and labs have come up with arbitrary reference ranges that minimize when insurance companies will have to pay for testosterone replacement treatment.  For example, when a man is in his early 20’s, his testosterone level may be 1000 ng/dL (nonograms per deciliter).  When he turns 50, his testosterone may have dropped to 250 ng/dl however by insurance guidelines, his testosterone at 250 ng/dl is considered “normal”, despite a drop of 750 points.  This individual will not feel the same as they did when their testosterone was 1000 ng/dL nor will their body perform the same.  By replacing testosterone in men in their 50’s, we are able to obtain levels similar to those the men experienced in their 20’s.

Generally, testosterone levels are highest in the morning so blood testing should usually be completed early in the day, before 10 a.m. is ideal.  If tests confirm you have low testosterone, further testing can determine if a testicular disorder or a pituitary abnormality is the cause.  Based on specific signs and symptoms, additional studies can pinpoint the true cause.  These studies can include further hormone testing, semen analysis, pituitary imaging, genetic studies, and even testicular biopsy.

Testosterone testing also plays an important role in managing hypogonadism.  This helps your doctor determine the right dosage of medication, both initially and over time.

Now on to treatment….

Since I’m sure this answer is already longer and more in-depth then you wanted, I’ll keep the treatment options focused on men in your age group and older.  The treatment for adult male hypogonadism depends on the cause and whether you're concerned about fertility.  I am often asked by patients for a “natural” way to increase testosterone levels.  Some men are hoping to simply pop a supplement or to exercise to increase their testosterone to the levels they had in their 20’s. Wouldn’t it be nice for life to be that simple!  While exercise, specifically weight bearing exercises, can minimally increase testosterone levels, for a man age 40+, there is no “natural” way to increase testosterone levels sufficiently that a significant difference would be noticeable.  For hypogonadism caused by testicular failure (i.e. such as which occurs with age), doctors use male hormone replacement therapy (testosterone replacement therapy, or TRT).  TRT can restore muscle strength and prevent bone loss.  In addition, men receiving TRT may experience less fatigue, increased energy, increased sex drive, improved erectile function, better sleep,improved concentration and sense of well-being.

Testosterone replacement therapy can cause fertility issues due to the negative feed-back system to the hypothalamus and testicles.  If the testicles detect more than enough circulating testosterone, they will decrease their production of testosterone and sperm causing a man to become infertile.  If fertility issues are not a concern (i.e. you do not plan to have children in the future) testosterone replacement may be used alone.  If fertility is an issue, another hormone, HCG (Human Chorionic Gonadotropin), may be administered to block the negative feed back of testosterone levels to the testicles.  The use of HCG, concurrent with TRT is important for younger men that may still want to have children in the future.

If the pituitary gland is the problem, pituitary hormones may be given to stimulate sperm production and restore fertility.  A pituitary tumor may require surgical removal, medication, radiation or the replacement of other hormones.

Several testosterone delivery methods exist.  Choosing a specific therapy depends on your preference of a particular delivery system, your lifestyle, the side effects, and the cost.  Typical methods include: 1) Testosterone injections (testosterone cypionate, testosterone enanthate) are safe and effective.  Injections are given in a muscle.  Your symptoms might fluctuate between doses depending on the frequency of injections.  You or a family member can learn to give TRT injections at home.  If you're uncomfortable giving yourself injections, a nurse or doctor can give the injections.  Testosterone undecanoate (Aveed), an injection recently approved by the Food and Drug Administration, is injected less frequently but must be administered by a health care provider and can have serious side effects.  2) A patch containing testosterone (Androderm) can be applied each night to your back, abdomen, upper arm or thigh.  The site of the application is rotated to maintain seven-day intervals between applications to the same site, to lessen skin reactions.  3) There are several gel preparations available with different ways of applying them.  Depending on the brand, you either rub testosterone gel into your skin on your upper arm or shoulder (AndroGel, Testim, Vogelxo), apply with an applicator under each armpit (Axiron) or pump on your front and inner thigh (Fortesta).  As the gel dries, your body absorbs testosterone through your skin.  Gel application of testosterone replacement therapy appears to cause fewer skin reactions than the patches but the efficacy varies depending on how well your skin absorbs the testosterone, however you can’t shower or bathe for several hours after a gel application, to be sure it gets absorbed.  A potential side effect of the gel is the possibility of transferring the medication to another person, especially females.  Avoid skin-to-skin contact until the gel is completely dry or cover the area after an application, usually 4 or more hours.  4) Testosterone can be applied inside of the nostrils as a gel.  This option reduces the risk that medication will be transferred to another person through skin contact.  Nasal-delivered testosterone must be applied twice in each nostril, three times daily, which may be more inconvenient than other delivery methods and again greatly depends on your body’s ability to absorb the testosterone.
5) There are also implantable pellets.  Testosterone-containing pellets are implanted under the skin every four to six months.  This is a very popular option, as the pellets are placed during an easy, painless, office procedure and are maintenance free.

Unfortunately, there is no really good option for oral testosterone.  The testosterone molecule is too fragile to survive the human digestion process and the oral testosterone we do have are not recommended for long-term hormone replacement because they can cause serious liver problems.

All Testosterone therapy carries various risks, including contributing to sleep apnea, stimulating noncancerous growth of the prostate, enlarging breasts, limiting sperm production, stimulating growth of existing prostate cancer and blood clots forming in the veins.  Because of this, at Optimal Male we continue to monitor your blood while on any TRT to ensure that your testosterone replacement therapy is successful and that risks can be minimized or avoided.

I hope this answered your question Jose.  You can always schedule your free exam and consultation at Optimal Male Performance Center and have your testosterone checked to see if you are a good candidate for testosterone replacement therapy.

Be well,

Richard Freier, M.D.
Medical Director
Optimal Male Performance Center
Office: 239.596.8886

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