Do I have Low T?
- Signs and symptoms
- Finding a doc
- Lab Evaluation
- Treatment / options
What to Look For
MEN (and women with men you care about)! Listen Up!
None of you are getting younger and unless you are one of the lucky ones who has struck the genetic lottery many of you, to some degree, are starting to feel the effects of aging… fading energy, loss of strength and endurance, a decline in sexual interest or performance, irritability, depression, lack of mental acuity…
These can be normal “consequences” of aging. A healthy lifestyle and good diet can go a long way towards delaying these declines, but at some point, sooner for some than others, the march of time starts to catch up.
While it’s common for patients and doctors alike to appropriately address things like diminishing eyesight, bladder irritability, high blood pressure or blood sugar (diabetes), there are many, many men who have never had a proper hormone evaluation, let alone a meaningful conversation with a health care provider.
Declining testosterone is a biological guarantee. Usually, by the time a man hits 30 years of age (or soon thereafter), testosterone levels have peaked… and begin to fall. The process is typically gradual and usually, symptoms of declining testosterone develop slowly.
Genetics, lifestyle and nutrition choices (among other things) will affect the rate of decline. Many men can reach old age and still have enough testosterone to feel strong, healthy and vital. Others will begin to experience undesirable consequences that negatively affect their quality of life.
Some of the symptoms include:
- Low Energy, Stamina, Drive and Motivation
- Weight Gain
- Drop in Strength and Endurance
- Nagging Aches and Pains and Slow Recovery
- Poor Mood; Depression, Irritability, Anxiety
- Struggle with Focus, Concentration or Memory
- Declining Sexual Interest (Libido) and Performance, including Erectile Function
Low T, Andropause, male menopause, manopause… there are many names to characterize the phenomenon of declining, suboptimal testosterone levels. Whatever you call it, low testosterone is not a medical fad or a gimmick. It is simply a physiologic reality for many men and can contribute to mild symptoms for some or a relatively debilitating condition for others. For most the effects will fall somewhere in between.
Like any other non-routine medical concern, male hormone assessment is nothing to be taken lightly and is best evaluated and treated by a doctor with proper expertise and and plenty of experience.
A thorough evaluation requires a knowledgeable HRT (hormone replacement therapy) practitioner to properly assess hormone status and to help determine how suboptimal levels may be contributing to overall well-being. From the feedback we hear commonly, many men, even many who have regular interaction with healthcare providers, have never been offered any sort of hormone assessment. Many others have had some basic blood work completed upon request, but without meaningful feedback.
The reasons for the lack of diligence regarding male hormone assessment are fairly straightforward… medical schools are not doing a great job of educating their doctors-to-be on the subject, general care practitioners have a lot on their plate, and insurance companies are not all convinced that it’s something they want to thoroughly cover. On the last point, because hormone therapy primarily involves “bio-identical” replacement (of hormones), pharmaceutical companies are not able to create and patent products that are better than actual hormones… meaning the ability of drug companies to influence the cascade of treatment that is covered by insurance is greatly diminished. Testosterone is testosterone, estrogen is estrogen, etc… independent pharmacies can provide high-quality “compounded” hormones, largely leaving it to more independent practitioners to use these pharmacies to fulfill prescription needs.
What does all that mean for you? Well, it means that you are unlikely to stumble upon an HRT expert and corresponding treatment going through the usual healthcare channels. Occasionally (more likely rarely) a patient will come across a primary care doctor or possibly an endocrinologist or urologist who has trained themselves on the intricacies of hormone therapy… but more often than not finding comprehensive treatment that optimizes health outcomes and minimizes any potential side-effects will involve seeking out a practitioner who has developed the specialty through intense training and repeated patient interactions.
Testosterone is not the only important hormone to evaluate, but it is often a good place to start. Testosterone is commonly associated with strength and athletic performance, but it is misleading to think of in these narrow terms. As outlined above, many aspects of overall well-being are influenced by hormones.
Hormones are biological messengers that are vital to regulating almost every bodily function – from basic needs to functions orchestrated by complex organ systems – such as cardiovascular and neurologic.
While many hormones participate in the concert of physiological activity, for men, testosterone is the vital hormone particularly abundant in young adults that declines steadily with age. For women the hormone estrogen is similarly influential.
“Low T” is a term that is viewed skeptically by some within the medical community. Female menopause – a natural part of aging defined by hormonal changes – is a biological process that many women attempt to manage medically.
Curiously, the inevitable decline (with equally predictable health changes) in testosterone levels as a man ages presents health concerns that many doctors are not fully prepared to address.
What is not disputed is that testosterone levels do decline steadily (1-2% per year), generally beginning by the age of 30. Recently, more and more men are choosing to address prematurely low levels (or more “naturally” low levels at older ages) and confront this phenomenon under the care of an experienced hormone expert.
In assessing the potential benefits of treatment, lab work will be gathered and evaluated in the context of the unwanted declines in health or performance that prompt men to seek care. A male hormone evaluation will always and necessarily include looking at the “total” testosterone levels. But even a basic assessment should include a few other markers.
Beginning with testosterone, there can often be an important distinction between the total testosterone levels and how much of the total that is actually available to participate in the processes that affect our health – physically, mentally and emotionally. This refers to what we call “free” or “bioavailable” levels. It is not that uncommon for men to have an excess of “hormone binding proteins” that bind to hormones, effectively leaving an unusually high percentage of them unable to perform their duties.
What all that means is that a total testosterone reading can sometimes be misleading. Some patients may appear, through evaluation of the total, to have decent testosterone status. However, in effect, many actually have quite low levels. It’s an easy enough test to add to a lab panel, but becomes particularly important when a man is experiencing symptoms that suggest low testosterone but total testosterone readings are not conclusive.
A secondary hormone that must be evaluated and monitored with any testosterone treatment is estrogen. While estrogen is abundant in women, men have a small amount and sub-optimal levels, too much or too little, can also adversely affect a man’s well-being. Further, estrogen production is correlated with testosterone levels, so it becomes particularly important to monitor and manage with any comprehensive hormone treatment.
Other hormones that may be important to evaluate and manage include DHEA, pregnenolone and thyroid. As well, growth hormone status may be appropriate to assess. Lipid panels, blood sugar levels, cardiac markers and specific vitamin levels may also be indicated.
Screening and regular monitoring of blood cell counts (particularly red blood cells) and PSA – a marker for prostate health – also help guide treatment options and optimize outcomes.
With conclusive laboratory work and careful follow-up, properly administered hormone replacement therapy is an invaluable intervention for many men.
When considering a hormone treatment it is important to realize that it’s not a simple yes or no question. Not only are there multiple options to administer testosterone, but there are choices concerning “supplemental” components to use as well as dosing options to consider. A doctor with expertise with all the variables will be most equipped to identify a treatment plan that optimizes treatment outcomes.
By and large, the best way to administer a male hormone replacement program involves regular injections. Most commonly, injections are administered once a week and can be self-administered. Some patients will employ a spouse or partner to give the shots, while some may choose to come into the clinic office. Some patients find benefits from more frequent dosing, while going more than 10 days between injections is generally discouraged by those who specialize in the therapy.
Another common method of administering testosterone replacement is via a cream, gel or patch. These options are designed to be absorbed transdermally (through the skin). Topical testosterone replacement involves daily application of the hormone and requires that patients be careful about exposure to others before absorption or evaporation. Another complication for both patients and providers is that absorption from one patient to the next can vary significantly, often making finding an effective therapeutic dose challenging and sometimes unlikely. While transdermal therapy is effective for some, many other patients struggle to see satisfying results.
Another method of administration to be aware of is pellet “implants”. This therapy involves a minor office procedure by which the practitioner makes a small incision – typically into “fatty” tissue on the lower back – and inserts tic-tac sized pellets (usually 6-10) of hormones before closing the incision. The pellets are designed to “release” slowly – typically over 3-5 months – providing steady levels throughout that time.
The advantages of pellet insertion include avoiding regular dosing associated with injections (usu. weekly) or creams (daily) and the ability to achieve relatively consistent levels for months at a time. Unfortunately, pellets do have drawbacks. This method is not a great option for everyone, particularly younger patients and more active patients, when greater hormone demands can make effective therapeutic hormone levels difficult to achieve, even at the upper limits of dosing.
Additionally, patients who lack an excess of adipose (fatty) tissue in which to implant the pellets will not be good candidates. Other concerns include the possibility that pellets nearest the surface extrude from the incision or that the incision site otherwise fails to heal quickly. While pellets may be a good option for some it is rarely a good place to start when considering testosterone replacement therapy.
A couple of complementary items should almost always be considered to optimize testosterone therapy. One is a component that helps maintain estrogen in a desirable range (called an aromatase inhibitor or AI). Another is the hormone human chorionic gonadotropin (HCG) that is utilized to maintain testicular stimulation while on treatment, something that is otherwise compromised. Additional treatment options should always be considered on a case-to-case basis.
As with any medical intervention potential risks should be properly understood before initiating treatment. The biggest concerns with male hormone treatment involve prostate and cardiac health.
HRT is contraindicated for patients with existing prostate cancer, although many patients who have undergone successful treatment have started or resumed hormone therapy without incident. What is often mischaracterized is the risk that testosterone therapy will cause prostate issues, as there is not meaningful evidence to substantiate that claim.
Cardiac risk is another area where concerns often outweigh the actual risks. Without a doubt cardiac risk factors must be properly assessed and patients in higher risk categories for cardiac events such as stroke or heart attack must be treated with due precaution. However, a substantial, evolving amount of study is revealing carefully prescribed and monitored HRT to be beneficial to heart health. This makes sense as a clear relationship has been established between low testosterone levels and higher rates of adverse cardiac events in certain populations.
One thing we know is that testosterone will encourage red blood cell production. Increasing RBCs can be an important intervention for those whose health is negatively impacted by not having enough – a condition known as anemia. Even for those who are not anemic a few more RBCs typically won’t cause a problem. However, it is important that blood counts be maintained within a healthy physiologic range to avoid the possibility that higher than normal levels contribute to an adverse event. Accordingly, a diligent HRT will monitor blood counts regularly and make adjustments to therapy as needed.
There are a few other potential minor side-effects of male hormone treatment. Most side-effects will be avoided simply by working with an experienced practitioner who prescribes a treatment designed to optimize results while avoiding or at least minimizing side effects. Appropriate adjustments to the initial treatment will further mitigate any side-effects that do result from care. A suboptimal treatment will be more likely to result in one or more of the following side-effects:
- Oily skin
- Hair loss
- Mood swings / Irritability
- Breast tenderness
- Testicular shrinkage
- Ankle swelling
Patients should always report adverse effects to their care provider and a conscientious practitioner will be able to provide feedback and corrections to treatment that alleviate undesirable consequences.
As we age, we all can expect to see some declines in vitality. Ideally, declines are gradual, subtle and part of a relatively graceful aging process. Unfortunately, this ideal is often not a reflection of reality, even when considerable effort is devoted to a healthy lifestyle and good nutrition. Declines can be even more abrupt – and come sooner – for various reasons… such as when a diet is poor, physical activity is sparse and when there are genetic predispositions to certain imbalances, to name a few.
While there is no foolproof formula for maintaining an abundance of health, there are things that often help – for some subtly but noticeably, for others profoundly. Combining nutrition, lifestyle and exercise modification as needed, while addressing hormone status with a qualified practitioner can open doors to levels of physical, sexual, mental and emotional wellbeing that for many appear closed and locked behind them.