Testosterone Deficiency

This article originally appeared online at DrPullen.com, part of the HCPLive Network.

Male menopause, male hypogonadism, testosterone deficiency. All of these are names for a condition where the function of the testes to produce testosterone is failing. This is one of the more common concerns of men I see in the office and is a condition where usually lab testing to check serum testosterone levels is needed to confirm or exclude the diagnosis.

The cause of this condition is poorly understood in most cases, and the symptoms can be vague and subtle. In some cases the cause is genetic, and in others can be from surgery, chemotherapy or radiation therapy, but most commonly it is idiopathic. Low testosterone is more common in men with other health problems like diabetes, hypertension, and heart failure. Common symptoms are fatigue, lack of strength and stamina, poor libido, and less commonly erectile dysfunction. Diagnosis is made more difficult by the wide range of normal in serum testosterone levels, and by the fact that much of the circulating serum testosterone is protein bound, making not just the total but also the unbound, or free, testosterone important in deciding if treatment is needed.

Estimates on the prevalence of testosterone vary widely, but it is clear that the incidence increases with age, and most experts agree that both symptoms consistent with testosterone deficiency and a low serum testosterone level are needed to make the diagnosis.

A problem with treatment of low testosterone is that there is no orally bioavailable testosterone preparation available. Unlike estrogen deficiency in women, for which there are several oral preparations available, testosterone when taken orally is not absorbed from the gut in a bioavailable form, so treatment involves parenteral therapy. This can be as injected preparations, as trans-dermal gels or patches, or as trans-buccal products. All of these can be effective, but the only generic products are inject able. All of the others are brand-name only meds that cost approximately $250.-$300./ month or more. Injectable products like testosterone cypionate when bought in multiple dose vials can cost about $6-$10/month plus injection costs (www.drugstore.com pricing). A problem with injectible therapy is that although the injected medication is in a delayed absorption product, the serum levels are highest shortly after the injection, and wane throughout the month, so some men feel symptoms of low testosterone returning prior to the time of their next injection. When using the gels or patches it is important not to have children or pregnant women accidently get the gel on their skin by second hand contact.

There is no good evidence that taking testosterone supplementation delays the normal male aging process, and it is not indicated in persons with normal serum testosterone levels or in men without symptoms of testosterone deficiency. Side effects of testosterone treatment can include prostate gland growth and increased trouble urinating (men with prostate cancer cannot take testosterone), breast growth and tenderness, shrinkage of the testes and infertility, sleep apnea, and increased red blood cell counts (polycythemia).

In my experience male hypo-gonadism is likely under diagnosed and treated, but at times also inappropriately treated in men with other problems, like depression unrelated to their borderline testosterone levels.

Treatment success is better guided by resolution of bothersome symptoms than by checking testosterone levels on therapy. If you suspect you may have low testosterone as a cause of symptoms, ask your physician whether testing if indicated.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at DrPullen.com — A Medical Bog for the Informed Patient.