Do You Have Low Testosterone?

For 80 (!) years physicians have prescribed testosterone to men without being certain if it actually had any effect…other than raising testosterone levels.

The only FDA-approved indication for testosterone is hypogonadism, in which there’s an actual disorder of the male reproductive system that results in the body not producing enough testosterone. Causes of hypogonadism include testicular damage from mumps, a genetic condition called Klinefelter syndrome, or problems with the pituitary gland, your body’s master gland.

Doctors consider a diagnosis of low testosterone for men who experience low sex drive and low energy in general, a decrease in muscle mass (often despite regular exercise), weak erections, poor focus and concentration, and depression. There’s a normal decline in testosterone with age, but if a man between 40 and 65 comes to me with these symptoms, it’s worth checking his testosterone levels.

Just as a woman’s sex hormones, estrogen and progesterone, decline with age, so goes a man’s testosterone. Some women in estrogen decline experience what’s best described as menopause hell: frequent hot flashes, night sweats, disturbed sleep, mood issues, brain fog, and sex drive a distant memory, all a result of declining sex hormones.

Whether the mental fogginess is caused by low estrogen or by chronically interrupted sleep is uncertain, but menopause can be very uncomfortable. However, most of these symptoms respond to bioidentical hormone replacement therapy within a couple weeks.

If women experiencing virtually no menopause symptoms were to try hormone replacement therapy, they’d likely not notice much of anything.

Low sex hormones don’t always call for treatment
To rephrase, in both men and women low levels of sex hormones may cause no symptoms whatsoever and treatment would be a waste of time and money. This is yet another example of the medical school dictum “Treat the patient, not the lab test.”

Unlike the genuine discomfort some women experience at menopause, symptoms of declining testosterone are vague and may actually be unrelated to testosterone, indistinguishable from the vagaries of getting older.

The word “andropause” (intended to imply male menopause) has the ring of a Big Pharma neologism created to induce anxiety in aging male Baby Boomers who are feeling less than booming, but who are reluctant to confront the inevitable passage of time.

Driven by Adam Smith’s law of supply and demand, doctors around the world (myself included) measured testosterone levels and, crackerjack scientists that we were, concluded that by merely raising testosterone from a pathetic low to a punchy high we could help our patients beat time at its game and reverse aging.

Low T
A lot of women, especially those on hormones themselves, appreciated this construct. (Men did too.) The guy in your life exhausted and grumpy when he comes home from work? Looking a bit flabby? No longer the sexual stallion you married? Maybe you, too, thought, “I wonder if he has low T?”

“Low T.” As damning as Hester Prynne’s Scarlet A.

“Honey, when you go in for your check-up, ask the doctor about your testosterone.”

Everyone, doctors and patients alike, took a major leap of faith by equating “High T” with a better life. Smelling the proverbial meat a-cookin,’ Big Pharma poured tens of millions into TV ads and drug rep visits to doctors. Do you remember those old Charles Atlas ads on the back of comic books? Here’s what they looked like. Yes, Big Pharma was selling that promise without all the hard work.

And yet the results were murky
What muddied up everything was this: while every one of Big Pharma’s testosterone treatments might raise a guy’s testosterone number, patients themselves weren’t reporting any dramatic symptom improvements. There seemed to be a short-lived, overall better sense of well-being, but it didn’t last. Maybe an upturn in libido, some improvement with erectile dysfunction (for that, testosterone can’t hold a candle to Viagra), but it was fleeting. Couple of months, at best.

Moreover, testosterone is not without risks, though fortunately they’re rare. There’s an increased frequency of heart attacks when testosterone is given to men over 65 with existing heart disease and increased risks for prostate enlargement and prostate cancer.

Most doctors (and again I include myself) who prescribed testosterone felt that the general lack of results with the Big Pharma products was due to the products themselves. The FDA-approved concentration of the prescription cream or gel provides a daily dose of 50 mg/ml, applied once daily to the upper arm or thigh. This was just insufficient, capable of raising blood testosterone levels a few points, but not enough to produce clinical results.

Stronger T
One way to improve your numbers and continue the convenience of topical testosterone is to have your doctor prescribe a stronger concentration (100 mg/ml or higher). This would be individually prepared for you by a compounding pharmacy. Another alternative to boost your T is to apply the cream/gel to the scrotum, where the skin is much thinner and absorption is better. This was proven in a clinical study.

Despite this, a new position paper from the American College of Physicians recommends bypassing the currently available FDA products as too weak and moving directly to testosterone injections. These definitely raise testosterone promptly, are inexpensive, and can be self-administered, though the health risks remain. There are even YouTube clips showing you the injection technique (clearly, you need to be OK with needles for this option).

The conclusion is simply this: as a man ages, his testosterone slowly falls, but without the overt misery many women experience as falling estrogen levels drop them into menopause hell. The alleged benefits of using one of the Big Pharma testosterone creams to increase your T number may subject you to one of the rare risks of testosterone without much clinical benefit.

If you have symptoms of low testosterone, first get your blood level measured. If it’s low, try applying the Big Pharma cream/gel or the higher-intensity compounded ones to your scrotum. Or just go directly to testosterone injections.

A few weeks later, have your levels retested. They will likely be higher, but think carefully about whether you’re actually feeling better. Have your alleged low-T symptoms improved?

If you can honestly say there’s not much difference with or without testosterone replacement, then don’t bother with the stuff. You’ll be taking all the risks (heart, prostate) with none of the benefits.

Or try an herbal blend
Interestingly, there’s an herbal blend that stimulates the body to make more of its own testosterone. Testosterone Formula contains vitamins, minerals, and herbs that support and maintain healthy T levels. While there have been no clinical trials on this product, there’s an important difference in action between pharmacologic T and this supplement. The herbs it contains are three adaptogens (ginseng the best known) that work by helping the body adapt to stress and function optimally.

When you take Testosterone Formula, everything involved in the body’s manufacture of testosterone functions more efficiently and, as a result, for many men there’s a slight rise in T levels. Note the “slight.” Nothing in comparison to testosterone injections.

By the way, using adaptogens to improve natural function is the exact opposite of how prescription testosterone works. The high level of testosterone in prescription T literally turns off your ability to make your own. The same mechanism is at work with any hormone replacement (thyroid, estrogen). Don’t worry about this, though. If you decide to stop taking the prescription, you gland awakens and starts producing its own hormone again.

The most significant steps you can take to slow aging are less involved with testosterone than with lifestyle choices. You need to exercise regularly, maintain a healthy weight, eat a nutritious whole-foods diet, remain mentally active, avoid tobacco, and get regular check-ups to make sure you’re not developing a silent killer like diabetes or high blood pressure.

And remember to be philosophical about the inevitable. Even Charles Atlas finally died.

Be well,
David Edelberg, MD