All About Testosterone Replacement

Whether you’ve talked about it in the weight room, read about it in a magazine, or seen a commercial on TV, chances are you’ve heard about testosterone replacement. The current media storm  might lead one to believe this treatment is nothing but positive. But before you begin any kind of treatment, it’s important to understand the various therapies and discuss the pros and cons with your provider. If you think you may be low in testosterone, brush up on the basics before having that important conversation.

Testosterone is the hormone produced by the testicles that gives biological males characteristic traits like facial and body hair, a deep voice, and larger muscles. It’s also responsible for stimulating the growth of the penis at puberty, fueling libido, and playing a role in sperm production and bone growth.

Beginning around age 40, testosterone levels begin to fall by about one percent every year, but some men actually develop a condition known as hypogonadism, meaning the body doesn’t produce enough testosterone. This can occur for a variety of reasons, including injury or infection. For men with hypogonadism, testosterone replacement therapy may be the best course of treatment. But it may not be appropriate for many men who are simply experiencing a natural decline or have seen their testosterone levels fall due to an illness (like diabetes).

While a reasonably accurate estimation of normal testosterone levels range from about 300 to 900 nanograms per deciliter (ng/dL), there are several factors that can influence interpretation, including age, height/weight, the time of day the blood was drawn, and which particular lab test was used.

Approximately one in every four men over the age of 30 experiences low testosterone levels; however, some studies show that only about 5-6% of men with low testosterone experience symptoms.

In adult men, the symptoms of low testosterone include:

• Low libido
• Erectile dysfunction
• Fatigue
• Irritability
• Depression
• Trouble concentrating
• Decreased muscle mass
• Muscle soreness, and prolonged recovery times from exercise

The risks associated with low levels of testosterone include:

• Weakened bones
• Depression
• Erectile dysfunction
• One study suggests a higher risk of death from heart disease and other causes

Additionally, low testosterone has been linked to diabetes, obesity, and high blood pressure, but it’s unknown whether it’s the cause.

A review in The New England Journal of Medicine found that testosterone therapy can help men who have low testosterone (confirmed by at least two morning blood tests). It can improve sex drive, sexual activity, and, to a lesser extent, erections. Some men also notice small improvements in mood, energy, and walking ability.

The strongest and most reliable benefit is better sexual function, especially increased interest in sex and sexual activity. Physical changes include more muscle mass and strength, but improvements in overall physical performance and bone strength are modest and don’t happen in everyone. The treatment can also correct anemia (low red blood cell count) and slightly increase energy, particularly in men who were anemic before starting therapy.

According to the Endocrine Society’s guidelines, which are based on careful reviews of research, testosterone therapy in men who have low testosterone can lead to small but meaningful improvements in sex drive, sexual activity, and erections. The overall effects are modest, but they are consistent enough to be considered real and measurable.

You may have heard of some of the purported benefits including improved sex drive, mood, muscle mass, and bone density. And while it can be helpful, testosterone replacement isn’t right for everyone. There is little research that demonstrates its effectiveness in men with already-healthy levels of testosterone, and the small studies that have been done show mixed results.

Other reasons for the piqued interest in testosterone replacement therapy include a rise in the number of prescriptions written by health care providers, as well as possible past under-diagnosis. In addition, the American Diabetes Association now advises healthcare providers to ask men with diabetes about their sexual health and, based on their symptoms, may consider checking testosterone levels.

The risks associated with testosterone replacement therapies include:

• Increased risk of developing blood clots
• Excessively high red blood cell counts
• Acne
• Sleep apnea, or worsening sleep apnea if currently untreated
• Enlarged breasts
• Limited sperm production or testicle shrinkage
• Infertility
• Abnormal heart rhythms

There a variety of ways testosterone replacement therapy can be administered. These include:

Gels

• Pros:
  • Easiest therapies to administer
  • Very effective
• Cons:
  • Higher cost
  • Possible irritation to skin or eyes
  • Potential of gel rubbing off on someone else

Injections

• Pros:
  • Variable dosing regimens, with infrequent injections (from once weekly up to once monthly)
  • Relatively inexpensive
• Cons:
  • Testosterone levels can be difficult to control (too high after injection, too low before next injection)

Patch

• Pros:
  • Easy to use (applied nightly on different spots)
• Cons:
  • Possible skin irritation

Tablet

• Pros:
  • Pills don’t have to be chewed or swallowed—they mold to the upper gum so eating and drinking is possible
• Cons:
  • Irritation of the gums
  • Toothache
  • Bitter taste
  • Must be replaced every 12 hours

Intranasal (Natesto)

• Pros:
  • Easy to use
• Cons:
  • Must be administered 3 times a day
  • Cost

If hypogonadism is not your issue, and you’re just looking to maintain healthy levels of testosterone, there are plenty of lifestyle changes you can make:

• Get enough good quality sleep–you can get enough sleep without it being good sleep and that can still negatively impact testosterone levels–quality sleep is critical.
• Maintain a healthy weight.
• Exercise often - both cardiovascular and weight-lifting activities can be helpful. But take care not to overdo it - excessive exercise (multiple hours of high-intensity exercise daily or running more than 30-40 miles per week) can lower testosterone levels.
• Manage stress.
• Eat a healthy diet with emphasis on leafy green vegetables, whole grains and lean proteins.
• Reduce alcohol, caffeine and other stimulants.
• Talk to your provider if you are taking opioids, glucocorticoids, and anabolic steroids, which can all cause a drop in testosterone.

Testosterone therapy has the potential to have a positive impact on one’s life when utilized in the appropriate circumstances, but medical intervention is never without risk. If you do choose to investigate testosterone replacement, be especially cautious when considering supplements purporting hormonal benefits, and discuss all prescription and over-the-counter supplements and medications with your provider before starting a treatment regimen.