What is Testosterone Deficiency (TD)?
Testosterone is the predominant male hormone and men have levels ten times higher than women. It is often stated that testosterone levels fall with age but 80% of men maintain normal levels throughout life. Terminology is very confusing. There is no “male menopause” or “andropause”. In the United States the term "low T” is used. The established medical term is HYPOGONADISM.
Guidelines suggest that men with a total testosterone of less than 8nmol/l usually need treatment. Those between 8 and 12 nmol/l may need treatment according to symptoms and levels above 12 nmol/l do not usually need treatment.
How common is TD?
Around 20% of men will have low testosterone and symptoms at some time in their life but few of these are being diagnosed and treated. This is due to lack of awareness by patients and physicians, especially as symptoms are vague and often subject to incorrect diagnosis.
What causes TD?
TD is classified as either PRIMARY, due to disorders of the testes or SECONDARY, associated with disorders of the pituitary gland in the brain. Primary disorders of the testes include childhood mumps, tumours or injury. Secondary disorders may include tumours of the pituitary or drugs, especially pain-killers, opiates or cocaine. The most common cause of TD is type 2 diabetes and obesity. As many as 40% of men with type 2 diabetes have TD and guidelines suggest all men with type 2 diabetes and obesity should have testosterone measured. This link with obesity is complicated but is mainly due the high levels of a chemical termed aromatase produced by abdominal fat. Aromatase converts testosterone to oestrogen, the female hormone, and this can lead to “man-boobs” and shrunken testicles.
Why is TD important?
TD increases a man’s risk of heart disease and also the risk of developing type 2 diabetes. TD is also linked to increased mortality, frailty, increased bone fracture, sexual problems, depression and reduced quality of life.
Symptoms of TD
The most common symptoms of TD are loss of erections, especially in the morning, along with loss of libido and a general lack of enjoyment of sex. Many men notice excessive tiredness, falling asleep, sometimes at work or even driving. There is often decreased motivation, poor sleep, agitation, nervousness and depression. Many men note reduced physical strength and feel less able to exercise. Sometimes men just complain of less enjoyment in life. Occasionally there may be reduced beard growth or body hair.
Because many of these symptoms are vague, they are often put down to stress, hard work or simply getting older. Doctors often fail to consider TD and wrongly diagnose and treat men for depression.
TD and relationships?
Men often interpret the sexual symptoms as a “loss of manhood”. The most common response is to withdraw physical contact that might lead to sex. This usually takes the form of working longer hours or going to bed later. The partner interprets this response as meaning that “he no longer finds me desirable” or “he must be having another relationship”. The relationship can then deteriorate and either or both partners then wonder if “things might be better with somebody else”! Sexual problems in the partner will usually aggravate the problem. Having treated men with sexual problems for many years, I find that TD has often cost the man his first marriage and contact with his children. My job is to attempt to save his second marriage.
Lifestyle and TD
When TD is found in men who are overweight or obese, then weight loss alone can often return the testosterone to normal, but this might take many months, even years. Surgical treatments for obesity can be very effective but are not readily available and involve risks. Stopping causative drugs such as pain-killers and "recreational” drugs, especially cocaine and alcohol, can help.
How is TD Diagnosed?
A blood test for total testosterone is taken in the morning on two occasions and the diagnosis is based on these levels combined with the presence of symptoms. A questionnaire such as the Ageing Male Symptom Score may be used to assess symptoms.
Medical Treatment for TD
Testosterone therapy is usually prescribed as a gel applied to the skin each morning or as an injection given into the buttock every 10-12 weeks. The correct therapy is usually chosen after assessing the needs of the patient. Tablets are usually recognised as levels fluctuate and frequent dosing is required. Treatment is usually long-term and needs to be combined with life style change as appropriate. Sometimes, where a cause can be addressed or significant weight loss achieved, then therapy may be discontinued. In practical terms, men are often reluctant to discontinue a treatment when they have seen significant benefits.
Does treatment for TD work?
Generally speaking, the lower the testosterone pre-treatment, the greater the benefits from therapy. There is now very strong evidence that testosterone therapy in men with TD:
- Improves energy, mood and depression and enhances concentration levels
- Improves sexual function, erections, libido, morning erections and satisfaction
- Improves weight loss, loss of abdominal fat, increased muscle to fat ratio
- Increases physical strength, physical performance and walking distance
- Reduces anaemia and improves oxygenation of blood
- Increases bone density and probable reduced fracture risk
These improvements take time, and whilst mood and energy levels may improve within a few weeks, full effects on sexual function and bone may take 6-12 months or longer.
Therapy usually results in clinical improvements that make the patient more able and motivated to make lifestyle changes. Improvements seem to be progressive and are related to achieving target blood levels.
Men with other possible causes of erectile dysfunction, such as diabetes and high blood pressure, usually require medication such as sildenafil or tadalafil in combination with testosterone therapy.
What does the NHS provide?
Testosterone therapy is available on NHS prescription after proper diagnosis by a specialist. Regular monitoring and follow-up on an annual basis should be provided but, due to NHS workload issues, this is often not comprehensive and many patients prefer to be monitored and followed up by a specialist clinic.
Is testosterone therapy safe?
There is no evidence that testosterone therapy increases the risk of prostate cancer, on the contrary, men with low testosterone are known to be at risk of more aggressive forms of cancer. Prostate cancer is often diagnosed in later life when testosterone levels are lower. However, testosterone should not be prescribed to men with existing and active prostate cancer and hence all men are fully assessed and monitored long term, a service not routinely provided by the NHS.
There is also no evidence that therapy increases the risk of heart disease, in fact most studies show that low testosterone is associated with increased risk of, and reduces survival from, heart disease, and testosterone therapy seems to reverse this risk.
What other treatments are available?
Many men with TD also have vitamin D deficiency which needs treatment. Some might prefer dietary supplements to increase testosterone levels, such as DHEA, or to raise testosterone through lifestyle changes, such as exercise and diet. There is some evidence that increasing frequency by taking daily tadalafil, can raise testosterone levels, but this option might not suit all couples.