LOW TESTOSTERONE (hypogonadism) (Clearing up the confusion)

 

By: Dr. Rodney L. Dennis with Urology Centers of Alabama

There has been a lot of media attention given to low testosterone levels in men. Initially, there was a strong market push by the makers of testosterone supplements to have testosterone levels checked by their doctor if a man had low energy, fatigue, erectile dysfunction or low libido.  As a Urologist, I have seen a huge surge in patients who come in requesting that their “T level” be checked, no matter what other urologic problem they were being seen for. 

Currently, we are now seeing this same marketing, but also an overlap of advertising by lawyers looking for men who may have been adversely affected by testosterone treatment.  This coincides with media coverage of two recent articles that seemed to show an increased incidence of cardiovascular disease or strokes in men taking testosterone. I now have men coming in to my clinic requesting to be taken off testosterone or requesting clarification of the situation.

So, let me try to break this down into some basic facts which may help relieve some anxiety and better understand hypogonadism. 

First of all, the two studies mentioned above appear to be somewhat misleading and possibly flawed. The studies evaluated patients who already had some cardiovascular disease. Many prior studies have shown that testosterone could possibly be helpful in avoiding cardiovascular disease in certain patients.  The FDA is now doing a study to better clarify this confusion. However, my recommendation at this time is that if a patient is truly hypogonadal (low testosterone) and, symptomatic (i.e. decreased libido, fatigue, erectile dysfunction) then the benefit of getting his testosterone level back into a normal range probably outweighs the possible risks, unless the patient is elderly or has known cardiovascular problems.

However, I think it is important for men to realize that most cases of fatigue  and erectile dysfunction may not be related to low testosterone, and some men with low testosterone may have no symptoms at all.

There are some potential risks of testosterone supplements and starting this medication is something that should not be taken too lightly by the patient or the doctor.  For instance, for a male who is interested in having a pregnancy in the future, testosterone will prevent that by drastically reducing the sperm count.  Also, if a male has microscopic or unknown prostate cancer, this could cause the cancer to flourish.  It can also worsen prostate enlargement symptoms and also prevent the testicles from producing their own testosterone and occasionally will cause testicular shrinkage.  Also, testosterone supplements may raise the red blood cell count or hematocrit which could possibly result in thickening of the blood or blood clots. (It is always important for men to have their red blood cell counts checked before and during therapy).

Low testosterone may not be just a testicular problem. Some men with low testosterone may have secondary hypogonadism, which is a problem with LH (luteinizing hormone) production by the pituitary gland in the brain.  The LH has to tell the testicles to produce testosterone. Low levels of LH may occur because of many things including:  depression, head trauma, iron overload, steroid use by body builders, diabetes, sleep deprivation, and kallmann syndrome (a genetic disorder).

As you can see, it is very important to know the LH level in addition to the testosterone level to help determine where the problem is.  If the problem is in the testicles, the testosterone level is low and the LH level is high.  If the problem is in the brain, the testosterone is low and the LH level is normal or low. 

If the problem is in the brain, then the male may not even need to receive testosterone supplements. He may respond to a medicine called Clomid  (clomiphene citrate) which is a relatively inexpensive pill taken once a day or every other day.   Or, there is an injection called HCG (human chorionic gonadotropin) which can be given twice per week as an IM or sub q delivery. (Most men usually opt for the pill). 

One important thing to remember is that one low testosterone level is not sufficient to make the diagnosis of hypogonadism.  There need to be two separate testosterone levels checked in the mornings, as this is when the levels are most accurate.  Based on current knowledge, my feeling is that a man should not be started on treatment for low testosterone unless two separate morning levels are low, and, the patient has symptoms of low testosterone.  Before starting treatment, my recommendation is to also obtain an LH and hematocrit levels.

I hope this information is helpful, but keep in mind that it is based on current knowledge and, based on the changes we have seen in the last two years, may very well change again in the future. 

 

Rodney L. Dennis, M.D.