Clinical Specialties : Male Urologic Health

Low Testosterone

Low serum testosterone, also known as hypogonadism or andropause, affects 40% of men over the age of 45. The prevalence of low testosterone increases with age. Studies have found that the incidence of low testosterone increases from approximately 20% of men over 60, to 30% of men over 70 and 50% of men over 80 years of age.

What are the signs of low testosterone in men?

There are both sexual and non-sexual signs and symptoms associated with low testosterone. Sexual symptoms include poor erectile function, low libido (desire for sex), weaker and fewer erections, and reduced sexual activity. Nonsexual symptoms include increased body fat, decreased energy and fatigue, reduced muscle mass, and depression.

Roughly 40% of men with high blood pressure and 40% of men with high cholesterol levels will have low testosterone levels. Additionally, approximately 50% of men with diabetes and 50% of obese men will have low testosterone. Studies have shown that 30% of men with HIV and 50% of men with AIDS will have low testosterone. Surprisingly, almost 75% of men with a history of chronic opioid use will have low testosterone levels.

How is hypogonadism diagnosed?

The diangosis of hypogonadism should start with careful evaluation by a physician experienced in diagnosing and managing patients with low testosterone. Many of the symptoms of androgen deficiency are non-specific and may be multifactorial in origin. Hence, symptoms may not be necessarily linked to low testosterone alone. This fact needs to be considered in the overall evaluation. The diagnosis should be made only after taking detailed medical history, physical examination, and obtaining appropriate blood tests. Symptoms will be evaluated using questionnaires such as the Aging Male Symptoms Scale or ADAM (Androgen Deficiency in the Aging Male).

Low testosterone is diagnosed by a blood test. There is controversy in what treatment threshold should be used to diagnose men with low testosterone. This threshold generally ranges from 300 to 400 ng/dL, as it is dependent on the laboratory analyzing the samples and age of the patient. Men younger than 40 years appear to have hypogonadal symptoms at a higher threshold of 400ng/dL. Testosterone therapy should not be prescribed for men with normal levels.

1. Scovell JM, Ramasamy R, Wilken N, Kovac JR, Lipshultz LI. Hypogonadal symptoms in young men are associated with a serum total testosterone threshold of 400ng/dL BJUI Int 2014 http://www.ncbi.nlm.nih.gov/pubmed/25345995 ) whereas middle-aged and elderly men have a testosterone threshold around 300 – 400 ng/dL

2. Ramasamy R, Wilken N, Scovell JM, Kovac JR, Lipshultz LI. Hypogonadal Symptoms Are Associated With Different Serum Testosterone Thresholds in Middle-aged and Elderly Men Urology. 2014 Dec;84(6):1378-82 http://www.ncbi.nlm.nih.gov/pubmed/25288577)

In addition to testosterone, blood tests such as estradiol, FSH and LH will help ascertain the causes of hypogonadism. Dr. Ramasamy has demonstrated that estradiol levels are important for libido and needs to be evaluated regularly in men on testosterone therapy. For more information on the importance of estradiol please read here).

What are the treatment options for men with hypogonadism?

There are many treatment options for symptomatic low testosterone. Testosterone replacement therapy may be in the form of topical gel, injections (both short and long acting), long acting pellets, patches, or oral inserts.

What to expect after treatment?

Testosterone Replacement has been shown to improve a man’s energy, libido (sex drive), muscle mass, sleep, erections, energy level, and depressed mood. Dr. Ramasamy has published on the improvement of symptoms following testosterone therapy.

Testosterone replacement has been shown to also decrease body fat in men. There is data now to support that giving testosterone to a patient with low testosterone may increase their bone mineral density and decrease their risk for a bone fracture. It is important to realize that testosterone treatment is considered lifelong therapy, just like in other chronic conditions. Stopping testosterone replacement will result in a decline in a man’s testosterone level due to testicular and / or pituitary failure.

Physicians will also likely check a PSA level (a screening test for prostate cancer) and a hematocrit level (a measurement of red blood cells in your body). A PSA level is checked to make sure that the patient does not have prostate cancer and a hematocrit level is checked because men receiving testosterone may experience an increase in their red blood cell count. If the hematocrit exceeds 50%, patients may be asked to donate blood and testosterone dosage may be decreased.

What are adverse effects of treatment?

The potential adverse effects of testosterone therapy should be discussed prior to treatment. These include acne, breast swelling or tenderness, increased red blood cell count, hair loss, swelling of the feet or ankles, reduced testicular size and infertility. Current evidence does not provide any definitive answers regarding the risks of testosterone therapy on prostate cancer and cardiovascular disease, and patients should be so informed. Although the association is weak, the FDA requires manufacturers of approved testosterone products to add labeling information about possible increased risk of heart attack and stroke. For more information on the adverse effects of testosterone therapy, please read the American Urological Association statement on testosterone therapy.

He was featured in Urology Times on the association between testosterone therapy and thrombotic risk in elderly men.

For Podcast on Low testosterone click here

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Ranjith Ramasamy, MD
Director of Male Reproductive Medicine and Surgery
Call: (305) 243-6090
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