LOW TESTOSTERONE DIAGNOSIS & TREATMENT

On an individual level, there are many known factors which could contribute to decreased testosterone production, including aging, specific hormonal disorders, chronic illnesses like obesity, diabetes, or kidney disease, testicular trauma, the use of certain medications, diet, various sleep disturbances like sleep apnea, stress/fatigue. More rarely things like pituitary tumors, certain genetic diseases, or radiation/chemotherapy may be the source. While these are rare, the signs are important to assess for.

At the population level, it is interesting to note that decades of research have shown a gradual decline in testosterone across all ages from what used to be a higher average - this is an effect seen even in younger men.2, 3 The reasons for this are not yet fully understood.

This is a great question, because asking it reveals an important principle in medicine, which is that you don’t treat a number - you treat a person. That may sound obvious on its face, but the mistake that’s often made is a patient may want to “fix” their T levels when they are asymptomatic. Or, conversely, a patient with a testosterone level within what many would consider a “normal” range may not want treatment despite the fact that their body is showing obvious signs of low testosterone.

The American Urology Association generally considers a Total Testosterone level below 300 ng/dL to be obvious and diagnosable hypogonadism (i.e., low testosterone).4 This is a rough number and should be used alongside Free Testosterone, Sex Hormone Binding Globulin (SHBG), and other lab levels to form a more complete picture of your hormonal health.

While the “300” number is the most cited and generally accepted, studies make the point that it likely isn’t specific enough for various age ranges, 5 and research varies broadly on whether that number is an appropriate cut-off. 6, 7 You might be starting to notice that the “normal” range is dying the death of a thousand qualifications. This is why it is critical to work with a physician who not only has an intricate understanding of the current science, but also your body’s unique presentation.

Some supplements have been shown to have a positive effect on testosterone, but research findings have generally been inconsistent. Further, even when positive findings have been discovered, they generally show only a mild effect on testosterone levels, 8 especially when compared to the immediate and potent effect of TRT.

Even further, research studies are usually conducted in relation to specific compounds, but supplement companies typically do not sell supplements in the form of the solitary ingredients that were studied, but rather in the form of a “proprietary blend.” These blends typically don’t inform the consumer of how much of the desired ingredient exists, to what level of quality it has been produced, and what form of the ingredient has been used. Contrast this with TRT, where the dosing, format, and formulation have a required level of transparency due to federal pharmaceutical regulatory standards.

Certain prescribed medications like clomiphene and tamoxifen have been used to increase testosterone levels. These work differently than TRT in that they encourage the body’s own systems to produce more testosterone. The effects of these medications are typically milder than TRT, and in many cases may only work for a short while, with other unintended hormonal effects. For patients interested in this as a treatment option, we are happy to work with you to determine if this is a viable option in your context.

The most important element to candidacy is not only to be clinically diagnosed with low testosterone levels via lab work, but to also be symptomatic. There are some finer points to figuring this out, so working with a physician who can obtain a targeted history with relevance to these complaints is critical.

When it comes to hormone replacement, genetics play a big part. Some patients experience pronounced responses to starting doses right away (these are commonly referred to as “hyper-responders”), while others may require gradual increases in the dosage over several months to obtain the desired effect, both in reference to blood levels and symptoms. Typically, some level of effect on symptoms is seen within the first week by most patients.

Testosterone itself is not produced in isolation, but as part of a larger, multi-hormone system called the “hypothalamic–pituitary–gonadal axis,” or GnRH axis, which regulates the levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are used by the testicles to make testosterone. Estrogen levels (which are actually vital in men within the right range) and prolactin levels may also be impacted by TRT. When selecting a provider to manage your TRT, you must consider finding someone who understands how to manage all of these hormones in harmony with one another.

As with any medical intervention, there are some risks associated with TRT. Among these are the risk for infertility, decreased sperm production, testicular atrophy, prostate cancer, negative cardiovascular outcomes (especially if there are pre-existing heart conditions), and a risk for blood clots, among others.

It should be known that the research on the long-term risk profile of testosterone therapy is debated in available medical literature - some argue that it may have a negative impact on life expectancy and cardiovascular outcomes, while others argue that it may actually decrease all-cause mortality. Your actual outcomes are likely to depend heavily on your physician’s domain expertise and the ongoing monitoring of your blood work.

Certainly! However, as TRT affects your normal hormone levels and the systems that regulate them, it is important to do this in a measured way to avoid rapid withdrawal effects. Sometimes, we offer short-term additional medications to help your hormone levels re-adjust. A calculated approach to stopping TRT can help mitigate withdrawal symptoms.

Taking TRT has the expected effect of lowering your body’s natural production of testosterone. After ceasing TRT, many patients return to baseline, but some do experience a long-lasting suppression in their hormone levels after therapy. Again, this can be sometimes be mitigated with other therapies.

One of the things that happens when you supplement with testosterone in order to return to normal levels is that your body suppresses its own internal production of testosterone. Since the internal production of testosterone is one of the key elements in sperm production and maturation, men who take exogenous (ie., from “outside the body”) testosterone typically see their sperm count and quality drop, along with semen volume. Typically, these return after ceasing TRT, though this is not guaranteed.