The diagnosis of low testosterone (low T), or hypogonadism, is on the rise. Approximately 13 million men are currently living with low testosterone, and another 500,000 are diagnosed each year. The American Urological Association (AUA) estimates that approximately four in 10 men over the age of 45 have low testosterone.
Testosterone is primarily a male hormone that is produced by the testicles. Testosterone plays an integral role in maintaining male sexual function, muscle mass, bone density, mood, cognition and sperm production.
The exact cause for low testosterone is often difficult to determine and varies from patient to patient. For example, men with health conditions such as high blood pressure, diabetes, obesity and high cholesterol are at higher risk for developing low testosterone. In rarer instances, men can have inherited deficits in the testicles or pituitary gland which limit their ability to produce testosterone. The latter situation is less common, and many of these men may have fertility issues.
A normal testosterone level is typically defined as a serum testosterone between 300ng/dL – 800ng/dL. There are a variety of symptoms caused by low testosterone. For example, men with low testosterone often report low sex drive, erectile dysfunction, less energy, reduced muscle mass, depression and decreased bone mineral density.
The good news is the majority of these symptoms will greatly improve once treatment is initiated.
Treatment options depend on a variety of factors. Most importantly, men need to know that using testosterone suppresses sperm production and may compromise future fertility. Therefore, there are two different arms of treatment, those that are fertility-friendly versus standard testosterone replacement therapy.
Fertility-friendly options are used in men with low testosterone who are concerned about future fertility. Clomiphene Citrate is a medication that is FDA-approved for women but has been safely used in men for many years. It is an oral tablet taken daily that blocks estrogen feedback to the brain. This helps to increase signals from the brain to the testicle, thereby increasing natural testosterone production. Another fertility-friendly option is hCG (human chorionic gonadotropin). Unfortunately, hCG tends to be more expensive and is usually injected three times a week. This medication also helps the testicles to increase their natural production of testosterone.
Standard testosterone replacement therapy (TRT) options consist of oral agents, topical (gels/patches), injections and pellets. With these treatment options, testosterone is supplied from outside the body (exogenous testosterone). Over time, the testicles will diminish their production of natural testosterone/sperm, and the body becomes dependent on the medication form.
Topical testosterone, or gels, is the most common form of therapy and are generally applied daily. Men must be cautious to clean application sites before having contact with a female or child. Injections come in many different forms, frequency and dosages. The dosage and frequency vary based on patient factors and physician prescribing patterns. The goal is to help the patients’ symptoms improve while limiting the highs and lows between injections. Testosterone pellets are another great option. The pellets are generally placed into the buttock area as a procedural-based office visit. The pellets are slow release and help to maintain stable testosterone levels over many months.
Monitoring men on testosterone replacement therapy (TRT) is extremely important. The American Urological Association recommends the following blood tests for men prior to starting and during testosterone therapy: testosterone, hematocrit and prostate-specific antigen (PSA). Concern for prostate cancer must be ruled out prior to starting men on TRT. This is accomplished by a digital rectal exam and PSA. A small portion of men on TRT will develop polycythemia or an increased red blood cell count. This theoretically increases the risk of heart attack and stroke. If elevated red blood cell counts are identified, then men may need to temporarily stop therapy and donate blood.
In January of 2016, the FDA issued a warning that men on TRT may potentially be at increased risk for heart attack and stroke. While numerous studies support the safety and efficacy of TRT, the American Urological Association recognizes there is some conflicting evidence regarding cardiovascular risk. Definitive studies that will provide a quality assessment of risk are currently pending.
The diagnosis of low testosterone is on the rise. There are many reasons why more men now are being diagnosed and treated than ever before. It is important for men to know the signs and symptoms of low testosterone and alert their physicians as concerns arise. There are many types of treatment options aimed at improving symptoms and potentially preserving fertility. Testosterone replacement therapy is generally a very safe and efficacious treatment for the appropriate patient when performed correctly.
Dr. Jared L. Moss is trained to treat all aspects of general urology, with a focus in men’s health. He specializes in male fertility, hypogonadism (low testosterone), erectile dysfunction, sexual dysfunction, and inflatable penile prosthesis (IPP). Moss has specialized microsurgical training to help restore men’s fertility. He performs microsurgical vasectomy reversals, microsurgical varicocelectomy, and microsurgical testicular sperm extraction on men who do not have sperm in their ejaculate. He also maintains a passion for helping men diagnosed with cancer, preserve their fertility. To schedule a consult with Dr. Moss, contact Regional Urology, 255 W. Bert Kouns Industrial Loop, Shreveport, 318-683-0041.