Hormones are chemical messengers that direct functioning of organs and tissues in the body. They have a big influence on how we feel day to day, and even on personality.
Testosterone is considered a male hormone, but is found in abundance in both men and women. When testosterone is too low, not only can you suffer serious health issues, your quality of life can be severely affected. Low testosterone affects men and women, but here I will focus on men. For the purposes of this article, we’ll just call it “low T”.
Millions of men in the US suffer from low testosterone. Despite this, very few will seek a diagnosis, and even fewer will be offered treatment. The pervasive thinking is that low T is a fact of aging, and many men also just don’t want to admit to any difficulties in the bedroom.
There are two classic types of low T in men: primary and secondary. These terms refer to where in the production cycle the deficiency originates:
Secondary hypogonadism is more common, and refers to impaired signaling of the testicular cells by the hypothalamus and pituitary. You see, testosterone production starts in the brain. These “master glands” send signals to the testicles to produce sperm and testosterone. When that isn’t happening, the testicles slow down or stop production and become dormant.
Primary hypogonadism is when the testicular cells stop producing testosterone at a normal rate despite proper signaling by the brain. This can occur with any damage to the testicles.
Why do some men have low Testosterone?
Low testosterone levels can be seen as early as the mid-thirties in men. There are many reasons for younger men to have low testosterone levels including head injuries that damage the pituitary gland, medications, steroid use or anabolic steroid abuse, obesity, autoimmune disease, pituitary tumors, testicular injury or damage, radiation or chemotherapy, cell phone exposure (carrying it in your front pocket), exposure to environmental toxins or endocrine disrupting chemicals, and lifestyle factors like inadequate nutrition, lack of sleep, and too much alcohol. In a younger man, the evaluation of low testosterone is more comprehensive, and treatment should be aimed at restoring normal function and natural hormone production rather than hormone replacement.
In older men, low testosterone can also occur as a result of aging. This is called “andropause” and is commonly thought of as the male version of menopause. It can be associated with many of the same symptoms as menopause, including mood changes, insomnia, and sexual dysfunction. Blood tests can easily identify low testosterone and confirm the diagnosis of andropause. It is also called “hypogonadism” or “testicular hypofunction” because it is usually due to lack of testicular (gonadal) production vs. a pituitary (brain) signaling issue. Andropause is a gradual, progressive decline in free and total testosterone that occurs over a period of years resulting in physiological and psychological changes which may vary from mild to severe. Symptoms can be caused by low testosterone, high estrogen or a combination of both.
Symptoms & Signs of declining testosterone levels may include:
- Muscular weakness, loss of lean body mass
- Decreased bone density
- Increased fat in the abdominal/chest area, weight gain
- Decreased body hair, wrinkles, sagging skin
- Mental and physical fatigue, lethargy
- Decline in physical performance and endurance
- Depression, memory loss, insomnia
- Decreased concentration, lack of ambition, lack of motivation
- Increased joint pain, muscle stiffness, decreased coordination
- Decreased libido, erectile dysfunction, impotence
- Increased blood sugar, elevated cholesterol
What I see most often in my patients is fatigue (mostly in the early evening), insomnia or restless sleep, weight gain in the abdomen, loss of muscle tone, focus and memory deficits, irritability, lack of confidence, loss of motivation, mild to moderate depression, and anxiety. Surprisingly, low libido and erectile dysfunction are some of the last symptoms to occur, but lack of morning erections can be an early sign. Consequences of low testosterone that are not always so obvious include osteopenia & osteoporosis, insulin resistance, and an increased risk of heart disease, autoimmune disease, rapid aging, and dementia.
How should Low T be evaluated?
A thorough evaluation for low T includes looking at all of the potential reasons for the condition. Committing to hormone replacement therapy is a serious decision. My feeling is that if there’s any possibility we can restore normal functioning, we should try. That’s why I do a very thorough intake and lab evaluation.
As part of my evaluation of low testosterone, I look at other hormones to see how well the hypothalamic/pituitary signaling is working. Thyroid and adrenal hormones are an important part of the picture. I also measure the signaling hormones TSH, LH & FSH, as well as things that can inhibit normal signaling, like estradiol, prolactin, inflammation, blood sugar, growth hormone, and micronutrient deficiencies. I also consider the possibility that low T could be due to lack of the proper building blocks. To make abundant testosterone you need cholesterol, DHEA, and zinc, to name just a few things. Your body also needs the proper stimulation to make testosterone, and can’t be distracted by too many other things or it will direct resources elsewhere.
There are also things that can inhibit the normal functioning of hormones, making a person feel like they have low T. One of these I see fairly often is high or low cortisol (adrenaline) from acute or chronic stress. This is an adrenal hormone that has a big effect on how other hormones work. Another is too much of a binding protein in the blood called SHBG that “hangs on” to testosterone, preventing the body from using it. Sometimes, when a patient has symptoms of low T despite everything looking normal, I look at cell membrane health. Your cell membranes are made from lipids (fats that come from what you eat) and when they aren’t constructed properly due to a poor diet they do not function properly. Hormones and other signaling molecules can’t get into the cell, and it can feel like you don’t have enough testosterone even when you do. Lastly, there is a condition called “Androgen Insensitivity Syndrome” that can be diagnosed with genetic testing. If you have this, you need higher levels to feel normal.
The conventional definition of low T is two separate lab draws documenting total testosterone below “reference range”. In my practice I define it by below range or low-end total testosterone, and/or low “free testosterone” (the unbound, or “available” fraction). This, combined with the presence of 2 or more of the classic symptoms, is all I need to see to take action. “Normal” testosterone levels vary greatly by age.
If I diagnose low T in a patient that has the potential for recovering his own testicular function, I will treat the underlying causes. This might include dietary changes to reduce inflammation, improve cell membrane health, and lower blood sugar, lifestyle changes to improve resistance to stress, weight loss, resistance training, targeted supplementation for nutrient deficiencies, a prescription for increased sexual activity, and measures to improve digestion and gut health. You can expect that it may take 6 months or more to see meaningful changes.
I may use off-label medications and supplements to encourage testosterone production. Some of these are clomiphene (commercially available) or enclomiphene (compounded), Kisspeptin, CJC 1295 / Ipamorelin, Gonadarelin, DHEA, Pregnenolone, dessicated organ meat complex, Vitamin D3, magnesium and zinc. I may also recommend morning sunlight, grounding, red light therapy and cold immersion therapy.
I highly recommend this article for more information on all of the things you can do to raise it naturally:
https://thereadystate.com/blogs/a-guide-to-raising-testosterone-naturally/
Testosterone Replacement Therapy
If despite all of the proper measures we can’t get your levels up naturally, or if you have primary hypogonadism, I will recommend and prescribe testosterone replacement therapy (TRT).
Three treatment options are available. Testosterone can be administered in the form of a topical gel or cream applied to the skin, by injection, or with pellet implants. I discuss each of these methods with my patients so we can decide together on the best option. They each have their benefits and drawbacks. Nothing is as good as optimal natural hormone production, unfortunately.
If there are contraindications to therapy, I will discuss these with you so you can make an informed choice. A personal history or significant family history of prostate cancer is one of those, although I do not think testosterone causes prostate cancer. Improper metabolism of it can, though, and if there is an existing cancer prior to therapy it can accelerate growth.
As with any therapy, there can be side effects. Elevation of your red blood cell count can occur, necessitating blood donation periodically. Mood and personality can change. Your relationship with your partner or spouse may change, so I always have a conversation about how that other person may be affected. Regular monitoring of certain lab tests like PSA, hematocrit, and estrogen levels are necessary to ensure safe treatment. If your PSA increases, you will need to be evaluated by a urologist. Since TRT will suppress what little testosterone production you have left, one of the side effects commonly seen is shrinkage of the testicles. If this bothers you, we can help prevent this with the addition of medications that stimulate the testicles to continue to function. Successful and safe TRT requires a close working relationship with your doctor, so I require that you be compliant with testing and follow-up visits.
Ideally, if you are a good candidate for TRT, I will quickly get you feeling better with the right method and dose. Within a week or two you will be feeling more like your old self, or even better! There’s nothing that makes me happier than seeing you strut into the office for a lab draw a few weeks later with some newfound mojo.
– Dr. Katherine Birchenough