HYPOGONADISM - Low Testosterone

DEFINITION:

Hypogonadism, commonly known as Low testosterone or just “Low T”, is a very common condition found in males of all ages.  Low testosterone occurs when the testes produce none, or a very small amount, of the hormone (testosterone).

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Balancing the Risks and benefits of testosterone therapy

WHO SUFFERS FROM LOW TESTOSTERONE

It has been reported in 2009 that almost 13 million men in the United States suffer from low testosterone (hypogonadism).  In 2010, that number increased to now over 15 million men in the United States who suffer from low testosterone (hypogonadism).   This number is rapidly growing because as more people are made aware of the symptoms, more men are being diagnosed and then treated for low testosterone (hypogonadism).

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It is estimated that anywhere from 20% up to 50% of men ages 50 through 70 suffer from low testosterone (hypogonadism).  Those who are obese are 2.5 times more likely to be diagnosed with low testosterone (hypogonadism).  If a man has diabetes or high blood pressure, that person may have a 2 times higher chance of having low testosterone (hypogonadism).  You may suffer from low testosterone (hypogonadism) and not even know it!

WHAT ARE THE SYMPTOMS OF LOW TESTOSTERONE ?

There are many symptoms for low testosterone (also called hypogonadism).  Some of these symptoms include; a low sex drive, erectile disfunction, fatigue (always tired), muscle loss, increase in fat, decrease in facial and body hair, loss of bone mass, infertility, shrinking testicles, achy muscles, shyness, depression, irritability, trouble sleeping, frequent urination, and an overall reduced quality of life.  Even with multiple symptoms, the only way to properly diagnose low testosterone (hypogonadism) is with a blood test.  A normal testosterone level will come back between 300 and 1,000 ng/dl. However, this ‘normal’ value varies from laboratory to laboratory is dependent upon the population they see and the way in which the test is performed. The current ‘best practice’ is to use the LCMS (liquid Chromatography Mass Spectrometry) method for determination of blood testosterone levels.

BEING DIAGNOSED WITH LOW TESTOSTERONE

If you are diagnosed with low testosterone (hypogonadism), it is very important to have a specialist fully evaluate you and discuss potential treatments.  Suffering from low testosterone (hypogonadism) can result in heart disease with an increased risk of death, depression, metabolic syndrome, diabetes, cognitive disorders, and osteoporosis.  Low testosterone (hypogonadism) affects all of the cardiovascular markers which lead to heart disease such as increased fat, raised glucose, increased blood pressure, and lower HDL.  It is estimated that those who suffer from low testosterone (hypogonadism) may have upwards of a 40% higher death rate over a 10 to 20 year period when compared with men who have normal testosterone levels. However, recent literature has also cautioned that in some men, testosterone supplementation has been implicated in cardiovascular events (eg heart attack and strokes). Only your physician specialist can advise the best treatment approach for you.

HOW CAN YOU BE TREATED FOR LOW TESTOSTERONE?

Low testosterone (hypogonadism) is most commonly treated with testosterone replacement therapy.  The majority of low testosterone (hypogonadism) treatment in the United States is done by prescribing a gel that is applied daily or an injection of testosterone done every one to two weeks.  There is also a patch is also a fairly common method for treating low testosterone (hypogonadism).  There are currently studies investigating novel oral testosterone therapy in the United States.  Previous oral testosterone treatment have shown to cause liver damage and therefore were removed from common use.  However, these newer agents appear, in initial studies, to be safe and effective.

Testosterone supplementation reduces or eliminates sperm production.  Therefore, men of reproductive age need to made aware of this and alternatives that might  increase their testosterone as well as preserve their sperm production. One such group of drugs used for this purpose are selective estrogen receptor modulators (SERM) which suppress the ability to attach to estrogen receptors in the brain.  This results in increases in the hormones call gonadotropins which act on the testis to increase the amount of testosterone released and sperm production.  Another group of drugs used to increase testosterone produced by the body are aromatase inhibitors that prevent the conversion of testosterone to estradiol. These are particularly effective in overweight men where the fat cells convert an excess amount of testosterone to estrogen resulting in both decreased circulating testosterone and decreased production of testosterone by the testes.

Therefore, the type of treatment you receive is critical. Before being placed on a testosterone therapy it is necessary to consult with a physician who is experienced in this specialized area of hormonal replacement therapy in men.

FAQ

1.       How common is low testosterone? Testosterone levels naturally decline with age. Men lose about 1 percent per year of their testosterone levels after age 40. Population studies suggest that 10% to 25% of men over 50 may have low testosterone. What is most interesting is that when asked about symptoms, though, only about one-half to two-thirds of these men report any symptoms of testosterone deficiency.

2.       Are the treatments for younger men with low T the same as this for older men with Low T? No, If men desire fertility than the treatment for low T should be very different. Testosterone supplementation lowers sperm count…sometimes for prolonged periods of time. For these younger patients other options exist such as selective estrogen receptor modulators (SERMs) or aromatase inhibitors that work to increase the hormones secreted from the pituitary to naturally increase testosterone and sperm production from the testes.

3.        Do men need to see their Doctor for an accurate diagnosis? Yes, for many reasons. Their are times that Low T should not be treated including diseases of prostate. Also, the cause of the Low T may result in treatment options other than testosterone supplementation. Often, osteopenia or osteoporosis, anemia and diabetes may be present with Low T and need to be evaluated and treated. Also, many medical conditions that result in Low T need to be treated either before testosterone supplementation or together with testosterone supplementation. Your Doctor is the best person to make this assessment and provide optimal care.

4.      What can cause Low T in a young man? Their are many genetic disease such as Klinefelter’s Syndrome that result in low T.  Also, men that have used anabolic steroids in the past may not return to their baseline testosterone levels. Trauma to the testis and testis infections as well as cancer and treatments for cancer that might affect testicular testosterone production.

5.       What’s the difference between primary and secondary hypogonadism? Primary hypogonadism refers to problems with testosterone production by the testis. Secondary hypogonadism refers to problems with the secretion of hormones from areas in the brain including the pituitary or hypothalamus that result in decreased stimulation to the testis to produce testosterone. 

6. Are confidence issues due to Low T?  Possibly Low T can be a contributing cause….however confidence issues are often multifactorial and can be also due to stressors in ones life such as work and relationship issues as well as health related issues.

7. Are there significant cardiovascular risks associated with testosterone supplementation? This is a question which experts disagree on. However, it is fair to say that if your medical evaluation suggests that your health is being adversely affected by a low testosterone that benefits of testosterone supplementation outweigh the risks.

I have developed an algorithm for the Evaluation and Management of Hypogonadism. This has been developed using current guidelines and my experience treating thousands of patients.

Please feel free to call (516-487-2700) or email me with any questions.