Careful assessments needed before testosterone therapy
Testosterone, or “T,” is the most important male sex hormone. It helps the body produce and maintain adult male sexual features and characteristics.
Testosterone replacement therapy (or simply testosterone therapy) is a treatment, which the National Institutes of Health states is used primarily to treat hypogonadism, also referred to as low testosterone, or “low T.” According to the NIH, low testosterone may occur due to injury to the testes, infection or cancer; however, the most common cause is simple aging. Testosterone levels in men decrease every year after age 30.
Dr. Loren Smith is a board-certified urologist at Willis- Knighton Pierremont. Smith said, “Low testosterone is a number and not a condition. However, it is commonly associated with many symptoms. In general, men with a low T may experience low energy levels, early fatigue, low libido or lack of desire for intercourse, depression, mood swings, lethargy, weight gain, poor muscle tone and sometimes erectile dysfunction. Low T has been linked to ‘thinning of the bones’ also.”
Smith said, “Many men present with poor quality erections and assume a low T is responsible. Low T itself rarely causes erectile dysfunction. I find that when men have ED and low T, most often it is due to low libido or a lack of desire for intercourse, which results in poor quality or lack of erections. Replacing T rarely improves erection quality in men who want to have sex.
“Not all men will benefit from T replacement. Because the range of normal values is so wide, I believe in treating symptoms rather than simply a low lab value. The symptoms I described before are legitimate, but there may be other reasons for a man to experience any or all of them. Because of this, men who present with symptoms and have low T levels deserve consideration for T replacement. If the symptoms do not improve, we may choose to stop the treatment. Having said this, most men with a value below 200 will experience symptoms, which will improve with treatment.”
Smith said, “I never use age as an excuse for medical conditions or to either avoid or offer treatments, but we must be very careful when treating older men for low T. Testosterone levels decline with age in normal and healthy men. We don’t have good numbers to know what an appropriate level really should be at various ages nor do we understand what constitutes ‘normal’ aging and tiredness versus that due to low T. Additionally, there may be significant cardiac and stroke risk as well as risk of blood clots with T replacement, and these may be more significant in elderly men. I am very careful about offering T replacement to my elderly patients but find myself evaluating their medical problems and overall functional level and comparing these to their degree of symptoms.”
Smith said, “The benefits of testosterone replacement are significant. Men often will feel better, will have significantly more energy, will no longer experience afternoon fatigue, will increase muscle mass and tone while losing weight and generally may enjoy life more. Often the patient’s partner will notice an increased energy level and libido.”
Smith said, “There are risks associated with T replacement. We can offer many different ways to replace low T, including topical creams and gels, injections and surgically implantable, long-acting pellets. Side effects may include skin irritation and rash, acne or discomfort at the site of administration. Testosterone replacement has been associated with blood clots, aggressive behavior, shrinking testicle size and low sperm counts. This creates a difficult situation when trying to screen men for prostate cancer in light of T replacement and a rising or elevated PSA. There is also growing data concerning the potential cardiac and stroke risk related to T replacement. This does not mean it is unsafe in everyone, but we need to take care to evaluate the entire patient and define the outcome we are looking for to safely continue treatment.
“T replacement is not new but has exploded into one of the most common reasons for men to visit a urologist over the past few years. In the right man, T replacement can be life- and relationship-changing. But it is not without risk, and we do not have enough long-term data to know all of the risks. The decision to treat needs to be based on not only the T level but also symptoms with a goal-based on improvement of those symptoms.”
Smith said, “If you are experiencing symptoms of low T, talk to your doctor or a local urologist about getting tested. It requires nothing more than a simple blood test. But remember that your body produces a ‘surge’ of testosterone every morning, so having the test drawn around 8 a.m. produces the most accurate result.”
