If you are a male aged 30-45 and was asked whether you have experienced tiredness, lack of energy, decreased sex drive, the answer is obvious as everybody will experience these from time to time. But do these symptoms really indicate a decreased testosterone, "Low T" as it is popularly known?
This has become a clever marketing slogan of testosterone hormone replacement therapy (TRT) in a 2.4 billion dollar industry, produced with catchy videos surely to draw your attention. It has caused such an increase of interest in the treatment of Low T that it has spawned Male Clinics around the country that freely dispense shots and gels to men looking for the fountain of youth , sometimes without checking the pretreatment hormone levels, or checking in possible causes of a low level. Interestingly, urologists, who are supposed to be specialists on this matter, are lower prescribers of the drug.
A "trial" of TRT for let's say 1 month results in a boost of testosterone and an improved sense of wellbeing, more energy and libido. The treatment however causes a drop or suppression of the testosterone produced by the body itself, even if it is marginally low. This will cause a softening and shrinkage of the testicles. Stopping the "trial" will result in a drop of testosterone even more than before the treatment and will cause the patient much more noticeable fatigue, lower sex drive, depression, and will be a potent and convincing motivator for the patient to continue treatment. If TRT is not resumed it might take 12-18 months to reach pretreatment levels, if ever. Although no studies have been done to show dependency on testosterone replacement, absence of proof does not mean proof of absence.
Recently TRT has come in the news in a negative light following a study which stated that testosterone might cause an increase in thromboembolic events, meaning an increased risk for strokes and heart attacks of 30%.Since then, this has been refuted by other articles touting the safety and efficacy of TRT. This makes it difficult to decide for the informed consumer whether to take the plunge or not. It is even difficult for the provider, with conflicting and contradictory information reported on a regular basis. The normal range of Testosterone is between 300-1000 ng/dl, although men with lower levels such as 270 ng can have a totally normal functioning body.
So what is testosterone?
It is a steroid hormone produced mainly by the testicles in men and small amounts by the ovaries in women, and in the adrenal glands in both. Men produce about 20-80 times the amount of testosterone as women, maintaining a blood level about 7 times of a female.
It is regulated by a very delicate and complex endocrine system called the hypothalamic-pituitary-gonadal axis which put the body on cruise control through an elaborate accelerator and brake mechanism. Changing one parameter might cause a cascade of effects throughout the system, the long-term effects of which are not clearly understood.
It has basically two functions, one of them is virilization such as deepening of the voice and facial hair and sperm production. The other one is anabolic effect such as increased muscle mass and bone density.
Testosterone starts rising before puberty and continues in the adult life until middle age, where there is a gradual decrease in the testosterone levels in men, often labeled as andropause, in reference to the female counterpart, the menopause , which however, is more abrupt in nature. A decrease in testosterone is associated with increased fat, obesity, depression, lower sex drive, osteoporosis and Alzheimer's disease. Testosterone has been associated with aggression and probably has evolutionary roots in survivability. High testosterone levels have often been correlated with criminality, especially violent crime offenders have a proportionally higher percentage of elevated levels of testosterone compared to the rest of the population. Castration has a pacifying effect on male behavior. (Note: castration as punishment or treatment for serial rapists is not effective because this is a much more complex problem than just testosterone levels alone).
Who needs TRT?
There are conditions where TRT is definitely indicated such as primary hypogonadism and secondary hypogonadism, either congenital or acquired.
If you are a middle aged men with a history of heart disease, COPD, or a college athlete trying to boost performance on and off the field, you probably should stay away from TRT, because the risks outweigh the benefits. With so many unanswered questions in the literature it is best to be very cautious in instituting TRT because the long-term side effects are still unknown. With testosterone easily obtainable even online, there is an overprescribing and marketing hype surrounding TRT and it is up to the individual to use a healthy dose of precaution before starting treatment.
If you are a healthy middle aged male with a sudden onset of libido changes, weight gain, depression that last longer than 6 months, have yourself checked, although a myriad of causes can result in those symptoms, and have him/her draw your testosterone level while at it.
It is best to talk to a physician specializing in andrology to make these determinations after looking at the overall picture.
Dr Lawrence S. Hakim
Cheif Medical Officer
Dr. Hakim is chairman of the Department of Urology at the Cleveland Clinic in Weston, Florida. He has been on the clinic's faculty since 1999. Previously, he was associate professor of urology and director of infertility at the University of Miami School of Medicine. His specialties include male and female sexual dysfunction, erectile dysfunction, male infertility and hormone replacement therapy. From 2009 to 2011, Dr. Hakim served on the Board of Directors of the Florida Urological Society; he was an Executive Board member of the Society of Urologic Prosthetic Surgeons from 2009 to 2010.