Male hypogonadism is a condition in which the testes are not producing enough testosterone. You have seen the commercials during sports broadcasts: “Do you suffer from ‘low-T’?” If you are male, maybe you have even wondered if your testosterone levels are “normal.” Well, with age and chronic illness, testosterone levels often do decline. Add to the puzzle that male hypogonadism symptoms are similar to those of many common chronic conditions in older men, and it can be difficult to diagnose the root cause of a man’s low testosterone level.
Testosterone replacement therapy for hypogonadism in older men is a hotly debated topic among physicians, especially since there is little research on potential long-term risks. So in an older man with low testosterone, a definitive diagnosis of hypogonadism must first be established. Here are some of the things your doctor will ask you and consider in their differential:
- Are you experiencing symptoms of hypogonadism such as sexual dysfunction, low energy, depression, or irritability? If you are not experiencing hypogonadal symptoms, testosterone replacement is not the appropriate course of treatment.
- Many physicians will want to confirm lab results showing a low testosterone level with a second set of labwork taken in the morning after fasting.
- It is common for testosterone levels to dip during acute illnesses and then return to the normal range in the weeks or months after recovery. If you were recently very ill, some healthcare providers will want to repeat testosterone level tests in three months to see if your levels are still low.
- There are several common conditions that alter sex hormone-binding globulin (SHBG) in older men. Doctors will often want to obtain a SHBG measurement and use those results to determine free testosterone levels. If your free testosterone is in the normal range, it definitively indicates that you donot have hypogonadism, thus testosterone therapy would not be warranted.
- Erectile dysfunction (ED) without other sexual symptoms is not indicative of hypogonadism. If your only symptom is ED, your doctor may prescribe a PDE5 inhibitor (such as Viagra or Cialis) but probably will not test your testosterone level.
If your doctor confirms through a physical exam and bloodwork that you do have hypogonadism, they may suggest testosterone replacement, but it is important to consider the unknown cardiovascular risks of testosterone therapy, especially for older patients. And even if diagnosed with hypogonadism, some patients are not appropriate candidates for testosterone replacement including people with:
- Prostate cancer or certain other prostate-related conditions
- Breast cancer (a disease which can occur in males)
- Polycythemia, an abnormally high concentration of hemoglobin in the blood
- Untreated obstructive sleep apnea
- Severe lower urinary symptoms
- Congestive heart failure that has not been controlled
If your doctor does prescribe testosterone therapy, several options are available:
- Topical gel–Used daily to produce consistent testosterone levels. It is important that women and children not be exposed to topical testosterone gels.
- Transdermal patch–Provides steady testosterone levels. Skin irritation at the patch site can be a problem for some patients.
- Intramuscular testosterone–The most cost-effective treatment option, an injection is given every two weeks. Some patients who have trouble with fluctuating testosterone levels between injections will need weekly injections of a lower dose.
All men using testosterone replacement therapy should be closely monitored by their healthcare provider, and testosterone levels should be retested regularly. For those using a gel or patch, testosterone should be measured 3 to 12 hours after application. For men using intramuscular testosterone, levels should be checked midway between injections.
After 4 to 6 months of prescription drug therapy, your doctor should check to see whether your low testosterone symptoms have improved. If they have not, it can be assumed that testosterone replacement is not working for you, and you should discontinue use.