“Hey Doc, do you think I have low T?” It’s a question that comes up quite a lot these days. Whereas 10 or 15 years ago, testosterone (T) was an occasional level to be checked, it is now a frequent part of a blood workup. This may be partly due to marketing. But, at the same time, low T is rather common, affecting perhaps 20% of men or more. That estimate keeps changing, partly because what is considered a normal T level keeps being changed as well.
Clinical low T is diagnosed when a low blood of testosterone is coupled with some of the signs or symptoms of low T. So, what are these signs and symptoms? They can include anemia, muscle wasting, reduced bone density, increased belly fat, sexual dysfunction, reduced sense of vitality, depressed mood, decreased motivation, increased irritability, difficulty concentrating, and/or hot flushes. Of course the problem is that these symptoms can have many other causes as well. Still, they are troublesome enough that a T level is worth checking if someone has some of them.
It is probably not a good idea to simply screen all men for low T and treat everyone whose number is low. Why? If someone isn’t having any of the symptoms of low T, it isn’t generally recommended that they be treated with T replacement. T replacement can occasionally have side effects. For example, if you have the beginnings of prostate cancer, T may stimulate it to grow more rapidly, though it doesn’t seem to increase the incidence of prostate cancer. T can also worsen benign enlargement of the prostate leading to increased difficulty with urination. Fluid retention and an increase in red blood cell count can also occur and thereby increase blood pressure, heart failure, heart attack and stroke in those who are prone. The numbers here don’t seem to be large, and there are some definite benefits to T replacement, but the point is that only those who will truly benefit should be treated with T replacement.
Perhaps surprisingly, sperm production can also be reduced by T replacement, thus impairing fertility. Sometimes the sperm count doesn’t readily return to normal after T replacement is stopped. So, for young men who may wish to have more children in the future, rather than directly giving T, there are other prescriptions such as clomiphene that can stimulate the body’s own T production without impairing the sperm count.
All those precautions being noted, if you have some of the symptoms of low T which we have listed, it makes sense to check a T level. If indeed your levels are low, and you have symptoms that correlate, it is certainly reasonable to consider a trial of testosterone replacement.
What are your choices for replacement? Testosterone is not absorbed well when swallowed. So, T can be given by injections, patches, gels and dissolvable oral pellets given by prescription. Levels can then be rechecked to ensure that adequate replacement has been given. The other key is to see whether the symptoms of low testosterone have actually improved substantially with replacement. T replacement is only continued if it actually helps your symptoms and doesn’t give troublesome side effects. Usually a 2-3 month trial is long enough for a man to know how much difference T replacement makes in how he feels. We have many men in our practice who find that T replacement has greatly improved their sense of well-being and who have no interest in going back to being without it.
This whole issue of when low testosterone is really pathologic, when it should be replaced, and for how long, is still an evolving story but more and more practical answers are being hammered out. So, if you’ve got the symptoms, get it checked, and then think it through with your doctor and decide whether to treat your low T and how.
Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835. He participates with some commercial insurance plans but also contracts with patients through Trinity DPC for those without insurance, belong to a cost sharing program, or are on Medicare.