TESTOSTERONE DEFFICIENCY
Testosterone is the male sex hormone, it is made in the testicles. Testosterone hormone levels are important to normal male sexual development and functions.
During puberty, it is testosterone that helps boys develop male features like body and facial hair, deeper voice, and muscle strength. Men also need testosterone to make sperm. Testosterone levels generally decrease with age, so older men tend to have low blood testosterone levels.
TESTOSTERONE'S ROLE
Testosterone is the major sex hormone in males and plays a number of important roles, such as:
- Growth and strength of bone
- The development of the penis and testes
- Libido (Sex drive)
- The deepening of the voice during puberty
- The appearance of facial and pubic hair starting at puberty
- Later in life, it may play a role in balding
- Size and strength of muscle
- Production of sperm
Adolescent boys with too little testosterone may not experience normal masculinization. For example, enlarging of the genitals may not occur appropriately, facial and body hair may be scant and the voice may not deepen as normal.
Testosterone may also help maintain normal mood. It is likely that there may be other important functions of this hormone that is yet to be discovered.
The production of testosterone in men is controlled by signals sent from the brain to the pituitary gland at the base of the brain. The pituitary gland then relays signals to the testes to produce testosterone. There is a feedback loop that closely regulates the amount of hormone in the blood so that when testosterone levels rise too high, the brain sends signals to the pituitary to reduce production.
Testosterone is not only important in men. Testosterone is produced in the ovaries and adrenal glands of women too. It happens to be one of several male sex hormones (androgens) in females.
These hormones in women are thought to have important effects on:
- Ovarian function
- Bone strength
- Sexual behavior, including normal libido
A proper balance between testosterone and estrogen is important for the ovaries to work normally. While the specifics are uncertain, it's possible that androgens also play an important role in normal brain function (including mood, sex drive and cognitive function).
What is Low Testosterone?
Some men have low testosterone levels, sometimes called testosterone deficiency (TD) or Low Testosterone (Low-T).
Low blood testosterone (Low-T) is generally identified as less than 300 nanograms per deciliter (ng/dL) on two tests obtained in the morning. Several symptoms or conditions may accompany TD:
- Fatigue - A term used to describe an overall feeling of tiredness or lack of energy.
- Erectile dysfunction - The inability to get and keep an erection firm enough for sex.
- Low sex drive - A term used to describe a decrease in sex drive that can interfere with sexual activity.
- Reduced lean muscle mass - The total weight of your body minus all the weight due to your fat mass.
- Irritability - Extreme irritability, or feeling irritable for an extended period, can sometimes indicate an underlying condition, such as an infection or diabetes.
- Depression - A common and serious medical illness that negatively affects how you feel, the way you think and how you act.
There are many other possible reasons for these symptoms, such as: opioid use, some congenital conditions that on is born with, loss of or harm to the testicles, diabetes, and obesity.
CAUSES OF LOW TESTOSTERONE
As a man ages, the amount of testosterone in his body gradually drops. This natural decline starts after age 30 and continues (about 1% per year) throughout his life span.
However, there are many other potential causes of low testosterone, including the following:
- Illnesses, both acute (short-term) and chronic (long-term)
- Abuse of alcohol
- Injury, trauma or interrupted blood supply to the testes
- Inflammatory conditions such as a disease that causes inflammation of the lungs and other organs (Sarcoidosis)
- Infection of the testes (orchitis)
- Chemotherapy for cancer
- Metabolic disorders such as too much iron in the body (hemochromatosis)
- Dysfunction or tumors of the pituitary gland
- Medications (e.g. opioids, hormones used to treat prostate cancer, and steroids)
- Liver Cirrhosis
- Renal (kidney) failure Chronic
- HIV/AIDS
- Abnormal development of the hypothalamus, a gland in the brain that controls many hormones (Kallman syndrome)
- High levels of prolactin (the milk-producing hormone)
- Ageing
- Obesity or extreme weight loss
- Pubertal delay
- Previous anabolic steroid abuse
- A genetic condition in which a male is born with an extra copy of the X chromosome (Klinefelter syndrome). Sometimes called XXY syndrome
- Uncontrolled type 2 diabetes mellitus
- Congenital defect
- Obstructive sleep apnea
- Estrogen excess (usually from an external or environmental source)
- Severe primary hypothyroidism
- Head injury (Trauma)
- Radiation exposure or prior surgery of the brain
SYMPTOMS OF TESTOSTERONE DEFICIENCY
The symptoms of testosterone deficiency are varied and depends on age.
Early childhood
- Penis does not grow to expected size (Micropenis)
- Small testes
Early teenage years (puberty)
- Poor growth (height) surge
- Underdeveloped larynx (Voice does not deepen)
- Late puberty or failure to go through full normal puberty
- Small testes and penis
- Poor or non-development of facial, body or pubic hair
- Poor muscle development
- Development of breast (Gynecomastia)
Adulthood
- Mood swings (low mood and easy irritability)
- Poor or difficult concentration
- Low energy (lethargy, low stamina)
- Reduced muscle strength
- Increased body fat
- Low interest in sex (Decreased libido)
- Difficulty getting and keeping erections
- Low semen volume
- Reduced beard or body hair growth
- Gynecomastia (breast development)
- Sweat and hot flushes,
- Thinning of bones (Osteoporosis)
- Easily fatigued
- Poor muscle strength
- Increased body fat
RISK FACTORS
Klinefelter's syndrome
A genetic deficiency in testosterone production. Affects a significant number of men.
Injury to the testes
Damage to testes can cause reduced testosterone production. The testes are prone to injury because they hang outside the body and are not protected by bone or muscle.
Un-descended testes
The testes develop within the abdomen and descend into the scrotum shortly before birth. In some cases one or both of the testes may not descend at birth. The condition usually corrects itself naturally within the first year of life but if it is not corrected in early childhood, the testes may not develop properly.
Mumps orchitis
Sometimes a mumps infection will involve the testes as well as the saliva glands. If this happens during adolescence or adulthood, long-term damage may occur that affects testosterone production.
Cancer and its treatment
Cancer of the testes or pituitary tumors can lead to low testosterone. Chemotherapy or radiation therapy can also interfere with testosterone production.
Hormone system imbalance
Kallman syndrome involves abnormal development of the hypothalamus and is a risk factor for low testosterone. Pituitary disorders can impair the release of hormones affecting normal testosterone production.
Chronic illnesses
Chronic illnesses (e.g. liver or kidney disease, metabolic syndrome and rheumatoid arthritis) may be risk factors for low testosterone.
Normal aging
Men normally experience some decline in testosterone level as they age.
Haemochromatosis
Hemochromatosis is a genetic disorder that causes the body to absorb too much iron from the diet. This iron can be deposited in various body organs including the hypothalamus, pituitary and testes. It is recognized as a common disorder and 1 in 200 men may be at risk of developing iron overload.
WHEN TO SEE A DOCTOR
Anyone who experiences one or more of the symptoms listed above should seek medical attention. A doctor may prescribe testosterone replacement therapy if a person displays a number of symptoms.
Low testosterone does not always present symptoms, and some people only learn about it after a routine physical examination.
To diagnose low testosterone, a doctor will often perform a physical evaluation and review the person's symptoms. The doctor may also request testing to look for additional signs.
For example, a bone density test can show diminished bone mass, one result of low testosterone.
DIAGNOSIS
Many symptoms may be attributed to Low Testosterone (Low-T), however total blood testosterone level is the most commonly used measure of testosterone deficiency. To make a diagnosis, the doctor will use other specific signs and symptoms in addition to testosterone blood level.
The doctor will do an exam and look for some of the signs and symptoms mentioned earlier in this article.
Health History
The doctor may ask about:
- Family history of diseases linked to Low-T
- Injury to the testicles
- Use of opiates
- Past or present use of anabolic steroids
- Mumps after puberty
- Headaches, visual field changes (possible symptoms of brain mass)
- How you developed at puberty
- History of head trauma
- Cranial (head) surgery/brain tumor or cranial irradiation
- Anosmia (loss of ability to smell)
- History of infection in the testicles
- Medication use (including opiates, psychotropics, glucocorticoids, and others)
- History of chemotherapy or irradiation (the process by which an object is exposed to radiation)
- History of stroke or heart attack
- History of unexplained anemia (lack of enough healthy red blood cells to carry adequate oxygen to your body's tissues)
PHYSICAL EXAMINATION
The doctor may check for the following:
Body Mass Index BMI or waist circumference for obesity
Metabolic syndrome. These are symptoms (seen together) of increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.
- Size of Prostate and any abnormalities
- Hair pattern, amount, and location
- enlarged breasts (Gynecomastia)
- Presence of testicles and their size
TESTING
The doctor may order the under listed blood tests:
Total testosterone level. This test should be done at two different times with samples taken before noon. Testosterone levels are often lower later in the day.
Luteinizing hormone (LH). This test is done to help find the cause of a Low-T level. This hormone controls how the body makes testosterone. Abnormal levels may mean a pituitary gland problem.
Blood prolactin level. High prolactin levels also may be a sign of pituitary problems or tumors. If prolactin level is high, the doctor may repeat the blood test to make sure there is no error.
Blood hemoglobin or Hgb. Before doing this test, your doctor will look for other reasons for low Hgb such as climate level (like climate altitude), sleep apnea, or tobacco smoking.
The following also may be done to help with further diagnosis:
Follicle stimulating hormone (FSH). This will check for sperm-making function if the patient wants to have children and will have to be done before any hormone therapy.
If there are breast symptoms, estradiol hormone test is done.
- Karyotype (Chromosome tests).
- Bone density tests.
- HbA1C blood test may be done for diabetes.
- MRI (magnetic resonance imaging) of the pituitary gland
TREATMENT
Low testosterone is treated with testosterone replacement therapy, which can be given in several different ways:
Intramuscular injections (into a muscle), usually every 10 to 14 days;
Testosterone patches; these are used every day and are applied to different parts of the body, including the buttocks, arms, back, and abdomen
Testosterone gels that are applied every day to the clean dry skin of the upper back and arms (the gels require care in making sure that the hormone is not accidentally transferred to another person or partner)
Testosterone pellets that are implanted under the skin every two months
BENEFITS OF TESTOSTERONE REPLACEMENT THERAPY
Potential benefits of testosterone replacement therapy may include:
- Avoiding problems related to delayed puberty in boys.
- Improved mental sharpness
- Loss of fat
- Protection against osteoporosis (increased bone density)
- Improved mood and sense of well-being
- Improved sexual function
- Greater muscle strength and physical performance
SIDE EFFECTS OF TESTOSTERONE REPLACEMENT THERAPY
The side effects of testosterone replacement therapy include:
- Acne or oily skin
- Mild fluid retention (might cause swelling in the ankles).
- Stimulation of the prostate, which can cause urination symptoms such as difficulty urinating
- Breast enlargement or tenderness
- Worsening of sleep apnea (a sleep disorder that results in frequent nighttime awakenings and daytime sleepiness)
- Smaller testicles
- Skin irritation (in patients receiving topical testosterone replacement)
Some laboratory abnormalities that can occur with testosterone replacement include:
- A decrease in sperm count, resulting in infertility, which is especially important in younger men who desire fertility
- Increase in prostate-specific antigen (PSA)
- Increase in red blood cell count
A digital rectal examination (DRE) of the prostate should be done at 3-6 months and 1 year after beginning therapy, and then every year after that.
DRE is recommended even for men who are not on testosterone replacement therapy, as an age-related prostate cancer screening which usually begins at age 50.
Hematocrit levels will also be checked before testosterone therapy starts, and then on a regular basis to make sure red blood cell levels remain normal.
WHO SHOULDN'T TAKE TESTOSTERONE REPLACEMENT THERAPY
Testosterone replacement therapy may cause the prostate to grow bigger. If a man has early prostate cancer, the concern is that testosterone may stimulate the cancer's growth. Therefore, men who have prostate cancer should not take testosterone replacement therapy. Meanwhile, it is important for all men considering testosterone replacement therapy to undergo prostate screening before starting this therapy.
Other men who should not take testosterone replacement therapy include those who have:
- Breast cancer
- A PSA measurement above 4
- An enlarged prostate resulting in urinary symptoms
- A lump on their prostate that has not been evaluated
- A higher-than-normal number of red blood cells (elevated hematocrit level)
- Severe congestive heart failure
- An untreated obstructive sleep apnea
Natural ways to boost testosterone levels
- Having a nutrient-rich diet can help improve testosterone levels.
- Weight loss and exercise can often increase testosterone levels.
While changes to the lifestyle and diet alone may not raise levels sufficiently, they often help.
It is important to keep in mind that men naturally lose testosterone as they age, and the potential benefits of lifestyle changes also decrease over time. Exercise, for example, often shows more significant results in younger people.
To support a boost in testosterone levels, the diet should be rich in nutrients. It may help to incorporate some of the following foods into the diet:
- Eggs
- Shellfish
- Beef
- Oysters
- Fortified cereals
- Tuna
- Milk enriched with vitamin D
- Beans
PREVENTION
Low testosterone that is caused by genetic conditions or damage to the testes or pituitary gland cannot be prevented, however a healthy lifestyle that includes good nutrition, exercise, weight management, and that avoids excessive use of alcohol and drugs can help keep testosterone levels normal.
