The ads on TV and radio are becoming more common. A man discusses an increasing sense of loss of energy, decreasing enjoyment of life’s activities, and dwindling sexual interest. “All of these,” he advises, “may be symptoms of low T.” But is this sudden media attention on low testosterone merely pharmaceutical hype or is there an actual medical basis for it?
Testosterone is an androgenic hormone produced in the testes by males and in the ovaries by females. (Yes, women have—and need—testosterone too!) As with estrogen, progesterone, pregnenolone, and DHEA, testosterone is derived from cholesterol.
While most people associate testosterone with muscle building, testosterone actually impacts every organ system in the body, and is therefore essential to health and vitality.
Testosterone exists in the body in two main forms—bound and free. Like most hormones, testosterone is carried through the blood bound to protein carriers. Only 2% of the total testosterone exists in the free or unbound state. Yet it is the free portion that is available for use by the body.
Testosterone levels fall for several reasons. The most common is age. After the age of 30, free T levels begin to fall about 1.5% per year. The main cause is not a primary testicular or ovarian failure. Rather, it is due to a decrease in signaling from the pituitary gland in the brain. This results in a condition known as “hypogonadism.”
Low T levels are also seen in association with various medical conditions, including coronary artery disease, diabetes, obesity, and in chronic use of opioid medication. (Be careful—an association does not mean cause-and-effect.)For example; people who are 20% over ideal body weight have an average 20% lower free T level. Serum free T levels are inversely related to arterial plaque formation in persons with Type II diabetes. In a recent 2011 study, 20% of men with Type II diabetes who had low T died over a 6-year period, compared with only 9% of those with normal T levels. In another study, low T levels after age 40 were associated with increased death rates over a 4-year period compared to those with normal T levels.
Testosterone replacement, on the other hand, has been shown to have a favorable impact on cardiovascular disease (decreased angina and improved lipids), the nervous system (including reducing the risk of developing Alzheimer’s Disease), bone density and osteoporosis, diabetes (decreased insulin resistance), and prostate health.
So what are the signs and symptoms of low T? Here are a few:
Low sex drive
Decreased energy
Irritability
Depression
Difficulty maintaining erections or decreased clitoral sensitivity
Decreased muscle mass
Insulin resistance
Decreased sense of well-being
Lowered exercise tolerance and slower recovery from exercise
Measuring T levels requires a blood test to check serum levels of total and free T. For optimum benefit, both from a symptoms perspective as well as from a preventive and anti-aging aspect, the goal of T replacement is to restore levels to those of a healthy 20-25 year-old.
Testosterone is best administered in one of two forms—topical and injectable. Topical T is available both commercially (as prescriptions such as Androgel® or Testim®) and through compounding pharmacies. One of the problems with the commercial prescriptions is the relatively low concentration of T they contain. These products are designed to treat persons with pathologically low T levels, but they often fail to raise T levels to the optimum range. Androderm®, for example is 1% testosterone. But a compounding pharmacy can prepare topical testosterone in 10% or even 20% concentrations, making it more efficient at raising T levels. Also, unlike commercial preparations, compounding has the benefit of being able to make small alterations in the prescription to “fine tune” the results.
Topical testosterone has the benefit of ease of application. But about 10% of people do not absorb medications well through the skin. Also, because of the increased conversion of testosterone to dihydrotestosterone in the skin, there is a slightly increased risk of hair loss with topical T. On the other hand, topical T has a slightly beneficial impact on lipid profiles (including raising HDL slightly). Women need to apply topical testosterone daily. Because men metabolize T much more rapidly, they need to apply it twice daily, as close to every 12 hours as possible. Daily application results in stable blood levels over time.
Injectable T may be used either when topical is not effective, when a higher dose of T is needed, or when a patient prefers the injectable form. T injections are commonly given into the muscle of the thigh or shoulder. Most physicians prescribe T injections anywhere from once a week to once a month. However, this is not very physiologic. It causes a large spike in T levels for a few days, and then levels fall off rapidly, resulting in roller coaster levels and symptoms.
A better way to inject T is to cut the weekly dose in half and inject twice a week. Yet even better is to divide the weekly dose into 7 equal portions and inject daily just under the skin. This is actually the most physiological, but also the most inconvenient.
Injectable T has a greater risk of causing gynecomastia (enlarged breast tissue in men) than does topical application. And injections have a neutral or slightly negative effect on lipids. When injecting T, it is imperative to avoid injecting in the abdominal area where there is fat, because the fat contains increased estrogen that will break down the T.
The risks of testosterone replacement are few. Contrary to popular belief, T replacement therapy does not cause prostate cancer. While you would not want to give T to someone with active prostate cancer, giving T will not cause cancer in someone with a normal prostate. (If testosterone caused prostate cancer then most 18-25 year olds would have cancer!)
Though rare, side effects of T replacement include acne, oily skin, and facial hair on women, hair loss for men (with topical), gynecomastia, and fluid retention. The side effects are easily treated. People who should not undergo T replacement include women who are pregnant or trying to get pregnant, and the partners of such women should also avoid T replacement. Once T replacement is initiated blood levels should be rechecked every 6 weeks and the dose adjusted until levels stabilize. Then labs are checked every 6-12 months.
Some clinicians also add the supplement chrysinwhen administering T to men. Chrysin helps to lower estrogen levels. However, other than persons with chronic coronary artery disease, there is absolutely no medical evidence that estrogen is harmful. In fact, estrogen levels are highest in young men. Estrogen protects against bone loss and osteoporosis, coronary artery disease, and Alzheimer’s disease and dementia. While you would not want to give additional estrogen to men, there is generally no need to reduce it.
In summary, testosterone is an essential hormone for maintaining health and for protecting against disease. Restoring T levels to the high end of normal is not only safe but also provides the optimum response for preventive and age management medicine.
Submitted by Paul Tortland, D.O. of Valley Sports Physicians and Orthopedic Medicine. For more information, call (860) 675-0357 or visit www.jockdoctors.com.