OVERVIEW

Low T, or Andropause, describes an emotional and physical change that many men experience as they age. Although the symptoms are generally related to aging, they are also associated with significant hormonal alterations. Andropause is a natural subtle decline in hormones that happens as men age. While medical professionals have known for a long time that the production of hormones by the testes slowly decreases as men age, interest has developed only recently in the clinical implications of andropause.

Andropause is also referred to as male menopause, male climacteric andropause, male andropause, late onset hypogonadism, or androgen decline in the aging male (ADAM). The term andropause may be considered somewhat inaccurate because the process is not universal and occurs subtly over time. In women, menopause occurs universally and usually happens dramatically, over a few years.

How Common is Low T in Men?:

Adam or andropause is a fairly common condition and the incidence of andropause (or hypogonadism) increases with age. The incidence from ages 40-49 is estimated between 2%-5%. From ages 50-59, the incidence is estimated between 6% and 40%. From ages 60-69, the incidence is estimated between 20%-45%. The incidence from ages 70-79 is estimated between 34% and 70%. The incidence of hypogonadism in men older than 80 is estimated at 91%. The spread of estimated ranges is quite large because different specialists use different ways to measure androgens and use different minimum levels to define andropause. The important thing is that if a patient feels there are reasons for concern, he should visit a doctor to learn more.

Can Low Testosterone Occur in Women?:

The medical community began researching and treating women with androgens (DHEA-S or testosterone) in the 1990’s.  There is more and more research attesting to its efficacy and safety.   However, there is little agreement about “normal” female testosterone levels. If a woman goes to a general physician and is told that her testosterone levels are “normal” all that means is that they are in a range of women who are not ill. It does not mean that the levels fall into a range that women need for optimal health and functioning.

However, the good news is that significant research continues in this area. Experts in the field continue to publish and have conferences dedicated to this area.  As a result, “normal levels” are being established although there is still a great deal of debate about the limits for each age. Each specialist in the field might have a slightly different range and may use different measurements for diagnosis including total testosterone, bioavailable testosterone, free androgen index or free testosterone.  Also, many specialists depend almost exclusively on symptoms, rather than blood levels.

A woman who would like her testosterone (and other hormone levels) assessed in order to better understand their effects on her sexual and overall health should find a specialist in the field of female sexuality and have them test her levels.  They should get a thorough history and place these results in context.  Finally, they must realize the complexity of female sexuality, and have a range of options for treatment/management available, including but not limited to hormonal treatment.  

We are very proud of our WOMEN’S CENTER staffed only by women, which provides a comprehensive, scientific, and warm atmosphere for women to address their sexual health.

SYMPTOMS

As we’ve said, andropause is rarely a sudden condition; it creeps up on you gradually. The main three symptoms are:

  • Decreased/low libido (interest in sex)
  • Erection issues
  • Decreased energy, muscle mass, and strength

Other symptoms, all of which are significant and all of which may be positively affected by treatment, include:

  • Osteoporosis (which can lead to increased bone fractures and breaks, as well as a decrease in height) 
  • Mood Changes
  • Intellectual Focus and Mental Acuity Changes
  • Decreased Body Hair

Decreased/Low Libido (Interest in Sex):

A decreased libido can be quite devastating for a man and for his partner.  Popular culture projects that all men should want sex all the time. This is of course not true, even for men with good libidos.  But when a man’s libido is significantly reduced, his partner will often feel rejected. The partner may feel that you are finding her/him unattractive, that you are having affair, and may feel that this situation is very unusual.

Libido can be diminished overall, or diminished in a particular situation.  A generalized decrease in libido usually means that a man loses interest in all kinds of sexual activity and in all contexts.  He may notice that he has less interest in masturbating.  He may be notice less an attractive woman/man that he sees or works with, compared to his baseline.  This of course means that he also has less interest in having relations with his partner.

If a man has a generalized decrease in libido, it is important that he communicate this to his partner.  This will help her/him to feel less rejected personally, and to put it in a more medical context.

In many cases, lack of interest in sex with your partner may be due both to an overall decrease in libido, combined with relationship issues. These issues must of course be addressed.

Libido is shockingly physiological.  Almost all men will have a lower libido as their testosterone level decreases.  Almost all men will have a higher libido when their testosterone levels increase.

Erection Issues:

Erection issues are strongly correlated with decreased testosterone levels.

The first thing that men may notice, are a decreased frequency and rigidity of their nocturnal or morning erections.  (Interestingly, this is often the first thing men notice when their testosterone levels are increased through treatment.)

More importantly, men may find they are having true erectile dysfunction, with difficulty getting and maintaining an erection during relations.  This is of course quite upsetting to man and to his partner.  

Erectile issues have many possible contributing factors, but a low testosterone is a significant one.  There are physiological changes in the penis with changes in testosterone levels.  Lower levels cause decreases in penile muscle, and increases in fat and fibrotic tissue.  Increasing testosterone levels causes an increase in penile muscle, and decreased in fat and fibrotic tissue.

It may however take up to six months for men to notice an improvement in their erections after starting treatment for low testosterone.

Decreased Energy/Muscle Mass/Strength

As men get older, our energy levels, muscle mass, and overall strength decrease.  However, this process is accelerated by decreased testosterone, and partially reversed by increasing testosterone.  It is important to note that a 60 year old man is not going to be 18 again!  It is important to view “anti-aging” clinics with suspicion.  However, it true that the vast majority of men with low testosterone levels, who receive treatment will have a partial reversal of these symptoms.

It is important to recognize that decrease strength and muscle mass, and conversely increased body fat, has significant negative implications for your overall health.  Most men gain much of their weight around their waist.  Some of this fat is simply subcutaneous (underneath the skin.)  However much of it surrounds internal organs.  This fat is particularly harmful, as not only does it contribute to the negative effects of other body fat, but is hormonally active in many negative ways.  We are increasingly learning how dangerous it is.

There are strong correlations between muscle mass and strength and “fragility”.  Fragile men live shorter and have lower quality of lives.  Increased body fat correlates strongly with diabetes, blood pressure, cardiac disease, and osteoporosis.  

Understand that these are symptom guidelines. Andropause affects different men in different ways and to different degrees. There are men who may get one or two of these symptoms, and may just notice the other symptoms occurring minimally or not at all.

As you work your way through this website, take the AMS Questionnaire (SHOULD HAVE A LINK TO AMS QUESTIONNAIRE) if you’re concerned that you might have andropause. It’s a simple and effective way to detect this condition. Now, just because you have a few of these symptoms doesn’t necessarily mean you have andropause. It could be some other cause, so a blood test is the best way to make a diagnosis.

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Diagnosis/Evaluation

 

The diagnosis of  Low Testosterone/Andropause will remain controversial for the foreseeable future.  It must be a combination of symptoms and laboratory data.

Symptoms:

The symptoms have been described above.  There are several validated questionnaires for the diagnosis of Andropause.  We feel that the most comprehensive, but user friendly one is the AMS (LINK).

In our center, we don’t just want to know about this aspect of you.  We are truly concerned about your overall health, both physical and psychological.  We are truly obsessed with men’s health.

You will fill out multiple questionnaires which we will review with you.  This include:

Overall Medical Questionnaire

AMS (see above)

Erection and Sexual Function

Depression and Anxiety

Sleep

Prostate and Urination Symptoms

We will take a careful and thorough history of what brought you to see us in the first place, how you are doing in general both physically and psychologically.

Once you have determined that you have the symptoms of andropause, then it is important to have your blood work tested.  

Treatment/Testosterone Replacement Therapy (TRT)

 

Overview:

The good news is that therapy is often very effective. The goals are to restore sexual functioning, increase libido and sense of well-being, prevention of osteoporosis by optimizing bone density, restoring muscle strength and improving mental functions. Our aim is to bring your levels of serum testosterone back to high normal levels, but beyond this, to normalize other hormones that may be abnormal as well.  These include, thyroid hormone, DHEA, estradiol (the main female hormone), and prolactin.

There are a number of ways to treat this condition including transdermal (through the skin) patches and gels, injections, and long-acting slow release pellets. Each modality has its own advantages and disadvantages.  Factors include: ability to get good levels, transmissibility to others, frequency and ease of use, and personal preference.  There is significant variability in price, especially if you do not have insurance, or for some reason your insurance plan does not pay for the medication.

It is important to note that testosterone is not available orally.  This is because all drugs absorbed in the stomach go to the liver first.  The liver thus gets a very high concentration of the medication.  In the case of testosterone, this can increase the chance of liver disease and cancer.  This is not the case when it is given by other modalities.

Topical Therapy/Applied to Skin or Mucous Membranes

Testosterone can be applied to the skin or to mucous membranes (the inside of the nose or mouth.)  Mixed with the testosterone are specific ingredients that help pull it through, and get it into the bloodstream, and then to the rest of your body.  Most often, this is the “first line” therapy.  The range of options and number of branded and generic preparations continues grow.

Locations:

The testosterone may be applied to the:

Inside lining of the cheek (buccal mucosa)

Inside of the nose (nasal mucosa)

As a skin patch

As a skin gel (including the back, chest, shoulders, arms, and thighs)

As a topical solution placed in the axilla (armpit)

Advantages/Disadvantages:

Daily Use:

Most men start with the topical medications, as they seem less intimidating.  If for some reason, he doesn’t like it, he just doesn’t have to do it the next day.

However, all of the topicals must be placed every day.  For some men, this is a non-issue.  For others this is a burden.  They may not be able to remember to put it on consistently.  They may not like the way it feels, smells, or tastes.

Variable Absorption:

Many men get good absorption and are able to get good blood testosterone levels.  However, a significant number of men are not able to absorb the medication, and never get good levels.

We always check levels, and switch to a different modality of testosterone replacement, if you are not getting good blood levels.  In general, we find that if a man is not getting good absorption with one gel or solution, he will not get good levels with a different one.  Typically, we will switch to a totally different method.

Activity Limitations:

Since the medications take some time to be absorbed, it is important not to remove them until they have had adequate time to be absorbed.

For the gels and solutions, this is a minimum of two hours.  Thus you should not shower, swim, or work-out until at least two hours after you have applied them.

For the intranasal (up the nose) gel, which is used three times daily, it is important not to sniff or blow your nose for an hour after use.

We usually suggest that for the

Transmissibility:

Though the gels and solutions take a minimum of two hours to be absorbed, they are not completely absorbed at this time.  Thus, it is important to shower prior to having skin to skin contact (to the area where the medication was applied.)  This is particularly important for women and children.  You can put on a T-shirt on prior to contact, and avoid transmissibility.

We usually have our patients apply their once daily medications at night, then sleep with a T-shirt, and shower in the morning, so they are finished with the application for the day.

Most men with pregnant wives or children are not particularly comfortable with using the gels or solutions.  There should be no transmissibility with the patch or the nasal gel.

Local Irritation:

Since the medication is placed on a particular surface (skin or mucosa) it may cause local irritation.

Local irritation seems to be most common with the patch, where our experience shows that almost no men can tolerate it.  Men who are very motivated to use the patch, can put a thin layer of hydrocortisone cream over the area first, which does seem to cut down on the irritation, without decreasing absorption.

For the topical gels and solutions, many men develop rashes or burning.  This may be true, even if they rotate the site of application.  However, many men have no skin issues whatsoever.

Injections:

Overview:

Testosterone may be injected into the layer of fat underneath the skin (subcutaneously) or into the muscle (intramuscularly- IM), usually the thigh, arm, or buttock.  This method has been used by physicians for years, and predates the use of topical testosterone by decades.  It is also the method that has been most abused by bodybuilders and athletes.

Method:

There are various formulations of injectable testosterone.  The most common are testosterone cypionate and testosterone enanthate.  Testosterone cypionate is the one that virtually all physicians, including us, prescribe.  

Traditionally, testosterone was injected only intramuscularly.  However, experts have recognized that it is also equally well absorbed when injected into the fat underneath the skin.  The needle is of course much shorter this way, and most men report preferring this technique.

The dosage is of course dependent on the individual.  In general, we are aiming for men to feel better, which usually correlates to being in the high normal range.  We have men injecting as low as 100 mg weekly, and as high as 220 mg weekly.  We follow both symptoms and blood work.

Some men notice the ups and downs correlated to the variable levels during the week.  These men are then counseled to split the dosage into two, and give themselves two injections per week.  This often avoids the peaks and valleys you may experience if the medication is given only once during the week.

Many physicians require their patients to come into the office for their injections, weekly.   This is of course a major burden for patients, and in fact most patients cannot follow through, and drop out of treatment.  Other physicians, using the same rationale, give their patients a large dosage on a biweekly or monthly basis.  However, this makes the patients have huge peaks and valleys in terms of how much is in their system, giving them ups and downs in terms of both symptoms and leading to greater side effects.

The rationale for requiring the patient to come into the office is that this is a restricted drug, and could be abused by the patient.  This makes no sense to us for several reasons.  The prescribing practitioner knows how much s/he is prescribing.  If the patient is running through it much faster than he should be, then there is a problem which is immediately apparent.  Also, if a patient wants to abuse steroids, he can just obtain them illegally at many gyms, and doesn’t need the physician in the first place.  By coming up with a reasonable and doable treatment, we feel it is more likely that patients will follow a safer medical regimen, rather than a more dangerous and unmonitored one.

How is Injectable Testosterone Supplied and How Much Does It Cost?:

Testosterone Cypionate comes in 10 cc and 1cc vials.  We strongly recommend our patients get the 10cc vials, as the liquid is very thick (viscous) and it is quite hard to empty the 1cc vials.  It is of course usually more expensive, per cc, to purchase 10 vials of 1cc than it is to purchase 1 vial of 10cc’s.  

It is available at almost all pharmacies, but sometimes needs to be ordered in advance.

Many drug plans will only pay for one month of medication at a time, which means they will not release a 10cc vial.  Fortunately, the medication is relatively inexpensive, and sometimes it is even cheaper to purchase the 10cc vial yourself (not using your prescription plan), then to pay a monthly co-pay and get the 1cc vials.  Using a website like goodrx.com, you can make the pharmacies compete for a reasonable price, and a 10cc vial should cost between 35 and 55 dollars.  This is without using your prescription plan.  Thus for patients without insurance, or with poor drug coverage, the injectable testosterone is by far the cheapest option.

Advantages/Disadvantages of Injectable Testosterone:

The advantages of injectable testosterone include:

Lowest Cost

Weekly or Biweekly injection (rather than daily application for topicals)

Dosing:

Unlike the topicals, the injectable testosterone is always absorbed.  We can always get men good levels using this modality.

The disadvantages of injectable testosterone include:

Not Bioidentical:

Testosterone cypionate is the oil-soluble 17 (beta)- cyclopentylpropionate ester of the androgenic hormone testosterone.  In order words, it is not bio-identical testosterone.  Men have been making their own testosterone since before we evolved into homo sapiens.  We have not been making testosterone cypionate.  Thus there may be some long term side effects of testosterone cypionate that we are not aware of.

Side-Effects:

There do seem to be more side effects from testosterone cypionate than from bioidentical testosterone.  These include more acne and more increases in hematocrit and estrogen.  Whether this is because there are more peaks and valleys in weekly or biweekly doses than with daily application (like the topicals) is unclear.  

Self-Injections can be Uncomfortable:

Testosterone cypionate is a very thick (viscous) liquid.  It is slightly difficult to draw up, and slightly difficult to draw up.  It is also somewhat uncomfortable to inject.

Compliance:

Men do have to remember to give themselves an injection every week, or twice weekly.  For some men this is simply not feasible, either because they dread it, or just simply can’t remember.

Testosterone Pellets:

Overview:

Testosterone pellets can be inserted in the fat underneath the skin (subcutaneously) once every three months.  This is done in the office, and takes less than ten minutes.  It has become the most popular method in our practise.

The pellets each contain 75 mg of testosterone.  Each pellet is approximately the size of a grain of rice.

In terms of dosing, we can always get good levels of testosterone which we can adjust simply by varying the number of pellets placed, all of which go through the same small skin incision.

How is it Done?:

Most of the time, the pellets are placed through a small incision in the skin of the buttock. The incision is so small it is closed with a butterfly bandage (steri-strip).  The location is chosen so that it is below the belt line, and above where you sit.

A local anesthetic is given with a fine needle.  We add bicarbonate to the local so that it does not burn as much.  (Most men actually find the local anesthetic more uncomfortable than the procedure.)

A small nick is made in the skin, and then the trochar is inserted.  The trochar is a hollow bored needle.  The needle is originally filled with a sharp insert, which allows it to be pushed through the fat.  Once the trocar has been pushed through the fat, the sharp insert is removed.  The pellets are then placed in the hollow needle.  They are then pushed into position by a second insert with a flat (rather than sharp) top.  Six to seven pellets may be pushed through at any time.  If more pellets are to be placed, the flat pusher is removed from the trochar and replaced with the sharp insert.  The trochar is not removed from the skin, but slightly repositioned, and then additional pellets can be placed.  Thus no matter how many pellets are placed, only once small skin incision is made.

A butterfly dressing is then put on the small nick to hold the edges together, and then a clean dressing.  The dressing is waterproof so a man can take a shower with it on.  The dressing can be removed after 48 hours.  The butterfly dressings then fall off on their own.

We ask our men to compress the site for and apply ice for a total of 15 minutes directly after the procedure, to limit swelling and bleeding.

Advantages/Disadvantages:

Advantages:

Compliance:

Men love the fact that they only need to think about this once every three months.  Once we have determined the correct dosage they only need to come to the office once every three months.

Levels:

Unlike the topicals, we can always get men good levels with the pellets.  The levels depend on the man himself of course, but also  how many pellets we place.

Bio-identical:

The testosterone pellets are bio-identical.  This means that they are exactly what your body and those of every person alive and all of our evolutionary ancestors have made!  Thus, any side effects would only be due to the dosing not to the actual medication itself.  In our practise we have a strong preference for bioidentical hormones for this exact reason.

Cost:

Most insurance companies pay for this medication and for the procedure.  However, if they do not, it is much more costly than the testosterone injections.

Disadvantages:

Discomfort:

Some men do not like the procedure.  Either they are intimidated by the procedure itself, or they have some post-procedure swelling, bruising,  and/or  discomfort.

Infection:

Slightly less than 1% of the time, the site can have a small infection.  This is not surprising, as the pellets represent a “foreign body.”  Almost invariably the man’s body responds by opening up the tract that the pellets went through and “spitting” them out.  We have never had an abscess or need to drain the area. We have not needed to give systemic antibiotics.

Testosterone Replacement Therapy (TRT)

Overview:

The two issues that concern men and their partners about testosterone replacement therapy (TRT) are:

What are its effects on the prostate?

Will I have a higher chance of getting prostate cancer?

Will my prostate get bigger and give me urination symptoms?

What are the cardiovascular effects?

Do I have a higher chance of having a heart attack, stroke, or blood clot with TRT?

Testosterone Effects on the Prostate:

It is important to address this point in depth, because this fear is often what makes men decide not to begin TRT, or to undertreat it, much to the determent of their overall health and well-being.

Though it is certain that this issue will continue to be debated for the foreseeable future, the overwhelming mass of evidence shows that :

Increasing Testosterone Levels does not increase a man’s chances of getting either Prostate Cancer of an Enlarged Prostate!

If this is the case, why is of such concern both to so many physicians (those not specializing in this field) and to patients?

We do know that men who have metastatic prostate cancer (it has spread to other organs) will have a slowing of their prostate cancer’s progression if their testosterone levels are brought to as close to zero as possible.  (Unfortunately, many if not most, will still die from the disease.)  It is thus true, that if we brought every man to a zero testosterone level, we would have fewer men with prostate cancer.  However, we would have a lot of unhappy and otherwise unhealthy men (let alone their partners.)  Clearly, no one would suggest that this be done to all men.

Because of this connection the fear has been that if we give men testosterone, it will act as “fuel to the fire.”  By this it is meant, that if there is any small amount of cancer in the prostate, giving a man extra testosterone will cause it to grow and spread.

However, there is significant data that this is not the case.

               Men with higher natural testosterone levels do not have a higher incidence of prostate cancer, which they would if more testosterone causes prostate cancer to grow.  In fact, there is significant data which shows that men with low levels of testosterone at higher risk of developing prostate cancer.  Why this is the case is not understood.

               There is no evidence that men who are given testosterone even have a jump in their PSA’s.  (An increased PSA would be evidence either of normal prostate tissue growth or of prostate cancer growth.)  

The current theory as to how testosterone affects the prostate is the “saturation model.”  The receptors for testosterone are completely occupied (saturated) at a testosterone level of about 300.  Thus if testosterone levels go from 300, to 600, to 900, no more gets into and affects the prostate.  As an illustration, if you soak a sponge in water, and then through it in the ocean, it is not going to get any wetter than it was before.  

This “saturation model” is supported by the fact that PSA levels (but not prostate cancer occurrence) increased when a man goes from significantly below 300 to 300 with treatment.  However,  PSA does not continue to increase after 300 is reached.

At this point, almost all major urological cancer centers and specialists are quite comfortable instituting TRT in men who have undergone radical prostatectomies, with clear margins, and no residual prostate cancer.  In fact, some centers are even comfortable with TRT for men with documented prostate cancer undergoing a surveillance rather than treatment protocol.  If indeed, the prostate receptors are saturated at 300 going higher, even in men with documented prostate cancer, should not make a difference.

Certainly, men without a diagnosis of prostate cancer should feel comfortable beginning TRT without worrying about increasing their chances of developing an enlarged prostate or prostate cancer.  

Unfortunately, it will probably take another generation of physicians , both generalists and endocrinologists, to be comfortable with this idea.

Every decision is medicine is based on a risk versus benefit analysis.  The tangible benefits of TRT may outweigh the theoretical, and almost assuredly wrong concern, about an increased risk of developing prostate cancer.

Cardiovascular Risks of Testosterone Replacement Therapy (TRT):

In December of 2013, two papers came out potentially linking the initiation of TRT with an increased risk of developing strokes or heart attacks.  One paper was simply found to be bad science, and most of it retracted.

Since then, multiple papers have shown that TRT actually has a beneficial effect on cardiovascular status, and reduced these risk.  These have been recognized by both the American Endocrinological Society and the American Urological Society.

Our experiences, which are of course anecdotal since we are one center, have been that TRT can have remarkably positive effects of cardiovascular status.  Many, if not most, men with low testosterone levels have great difficulty in getting themselves to exercise and watch their weight.  When they do, they have poor results and give up.  With a higher testosterone level, their energy levels improve, giving them more motivation to exercise and diet, and much better results for the same effort.  They “spiral up.”  We have seen remarkable changes in absolute weight but more importantly increases in muscle mass and decreased in body fat.  We have seen blood pressure, average blood sugar levels (HbA1c), and cholesterol levels decrease.  This is on top of the other positives our men are seeing (i.e. increased libido and energy, and better erections and mood.)

The controversy will continue to rage into the foreseeable future.  Lawyers will continue to look for patients for possible class action suits against drug companies manufacturing testosterone.  However, as mentioned above, every physician and patient must weigh the risks versus the benefits for every intervention.  It is almost inconceivable to us that the long term risk of TRT will outweigh the immediate and long term benefits.

Potential Side Effects from TRT:

Fluid retention:

It is possible, especially within the first few months of treatment, for a man to retain fluid. Studies of healthy older men have shown problems with fluid retention leading to ankle or leg swelling, worsening of high blood pressure, or congestive heart failure. It is unclear whether there would be an effect in men who are ill, for example, those with congestive heart failure.

Shut Down of Sperm Production (partial or complete):

Spermatogenesis (the production of sperm) in all men is dependent on production of testosterone by the testes. If testosterone is given from outside the testes (exogenous testosterone), as in testosterone replacement therapy, the testes will then stop producing their own testosterone. This will actually shut down sperm production either significantly or completely in almost all men. This may be a temporary or permanent effect.

It is very important that younger men who still plan to have a family take this into account.  Physicians specializing in TRT and fertility can manage men with low testosterone in other ways, that cause men to increase their own production of testosterone.  This can be done at the pituitary level (clomiphene citrate) or at the testicular level (HCG.)

In our experience, men feel better on either clomiphene citrate or HCG than they did at their baseline.  However, they usually do not feel as well as they would on pure testosterone.  Thus, here are men who “bank” their sperm (for more information on this subject visit OUR SPERM BANK LINK.) and then begin TRT.

Sleep Apnea:

Sleep apnea is a condition in which an individual stops breathing for periods of time while sleeping. This can have significant medical effects. In the past there have been reports that increased testosterone levels exacerbate pre-existing sleep apnea. However, a there is no recent data that supports this.

The severity of sleep apnea is very much dependent on a man’s weight, among other facts.  In our experience, since most lose body fat with TRT, their sleep apnea actually many improve.

Increased Estrogen Levels:

Testosterone is converted into estrogen by an enzyme called aromatase.  Thus the more testosterone there is in the body, the more estrogen.  It is unclear at what level, if any, increased estrogen becomes an issue for men.  Thus it is remains controversial whether men who have an increase in their estrogen levels because of TRT need treatment.

However, some men will respond to increased estrogen levels by developing some breast tissue.  The vast majority of the time, the first sign of this is not visually noticing breast growth, but by developing some breast or nipple tenderness.  

In these cases, a medication which inhibits aromatase (the enzyme that converts testosterone into estrogen) is given.  This almost invariably stops the breast and nipple tenderness, and reverses any breast growth that has occurred.

Increased Red Blood Cell Concentration (Polycythemia):

One of the most important side effects of testosterone replacement therapy can be an increase in the number of red blood cells (RBC’s) in the blood itself.  The percentage of the blood made up by the RBCs is called the “hematocrit.”

RBC’s carry the oxygen, and thus increasing the RBCs increases the oxygen carrying capacity of the blood. (Some athletes illegally engage in “doping” which involves giving themselves a transfusion of their own blood, in order to increase the exercise capacity before a sports event.)

For men with anemia (low percentage of RBCs  in the bloodstream) TRT by increasing their number of RBCs may actually help treat the anemia.  We have had patients come off of expensive anemia drugs with the use testosterone.

However, if  this percentage (HCT) becomes too high, it may cause a thickening or sludging of the blood, which may cause increased strokes, heart attacks, or blood clots.

This percentage is not well defined, but most experts feel that a man’s HCT should not be greater than 55%.

We check every man’s HCT every three months, while on TRT.  We encourage our men who increase their hematocrit to donate blood, which almost always takes care of the problem.  For some men who are not allowed to donate blood (either because of travel or medical history) we will sometimes take the blood from his arm, just as in blood donation, but dispose of it instead.  This is referred to as a “therapeutic phlebotomy.”

Though we monitor men rigorously for this, we have found that very few develop too a HCT, and all can be managed by blood donation, therapeutic phlebotomy, or a combination of both.  

Monitoring Men During Testosterone Treatment (TRT)

While you many start hormone replacement treatment for a variety of reasons, once you do it is usually maintained for life. Since patients must be monitored for the duration of time that they are on testosterone replacement, essentially, the monitoring is a lifetime commitment.  However, if you stop TRT, you will go back to the levels of testosterone you were at, or possibly slightly lower, and will no longer need monitoring.

Blood Tests and Follow-up:

There’s still differing thought about how men with testosterone replacement should be monitored. It’s clear that if you’ve begun testosterone replacement for a particular symptom, that symptom carefully observed. For example, a patient using testosterone because of problems with osteoporosis should have regular serial bone density screens. Patients with mood or libido changes must be carefully evaluated, too.

Once TRT has begun, hormone levels are rechecked after one month of treatment.  We also review symptoms with patients (but often don’t see any symptomatic changes at one month.)  If levels are not adequate, increased testosterone is prescribed, and levels rechecked after you have been on the new regimen for one month.

Once you are on an established regimen, we see every patient every three months, to monitor blood work and symptoms.  

What Are We Aiming For?:

Obviously, the ultimate goal is to make men healthier and feel and function better.

In terms of testosterone levels, we aim to be in the high normal range.  It is unclear what level of testosterone is “too much.”  However, we have found that most men feel better at higher normal levels rather than mid-range levels.

When Will I Notice Any Changes from Testosterone Replacement Therapy (TRT)?:

Most men will not notice any changes for the first couple of months on TRT.  (The exception is that many men will notice an increase in the frequency and rigidity of morning erections relatively soon after starting.)  

Many men come into their one month visit, convinced that they do not have an increased level of testosterone. Some of these men may be right, because, for example, the topical testosterone treatments may not be giving them good blood levels of testosterone.  However, many men will have excellent levels, but not feel any different.

A few men will actually feel almost euphoric after beginning treatment.  We get calls from men exclaiming that “I feel 18 again!!!!”  However, it is not possible for this last.  Their body gets used to this higher level, and though they feel better than they did before, they will not continue to feel 18 forever.

In terms of symptoms, most men will notice:

Increased Muscle Mass and Energy- at 4 months

Improved Erections- at 6 months

Increased Libdio- at 9 months.

Of course, every man is different, but we strongly feel that before beginning TRT, you should mentally commit to getting excellent levels for a year.  We see many men who have tried TRT, but inadequately.  They either do not get excellent levels, or do not stay on it for long enough, or usually both.  They come in saying that TRT does not make a difference for them.  Of course it doesn’t, if they haven’t gotten or stuck with proper treatment.

For about 90% of our men who get excellent hormone levels, and stay on their regimen for a year, TRT is a true game-changer, and they notice fairly dramatic changes.   Again, every decision in medicine is a risks versus benefits one, and in the case of TRT is fairly easy to make!

Monitoring Men During Testosterone Treatment (TRT)

While you may start hormone replacement treatment for a variety of reasons, once you do it is usually maintained for life. Since patients must be monitored for the duration of time that they are on testosterone replacement, essentially, the monitoring is a lifetime commitment.  However, if you stop TRT, you will go back to the levels of testosterone you were at, or possibly slightly lower, and will no longer need monitoring.

Blood Tests and Follow-up:

There’s still differing thought about how men with testosterone replacement should be monitored. It’s clear that if you’ve begun testosterone replacement for a particular symptom, that symptom carefully observed. For example, a patient using testosterone because of problems with osteoporosis should have regular serial bone density screens. Patients with mood or libido changes must be carefully evaluated, too.

Once TRT has begun, hormone levels are rechecked after one month of treatment.  We also review symptoms with patients (but often don’t see any symptomatic changes at one month.)  If levels are not adequate, increased testosterone is prescribed, and levels rechecked after you have been on the new regimen for one month.

Once you are on an established regimen, we see every patient every three months, to monitor blood work and symptoms.  

What Are We Aiming For?:

Obviously, the ultimate goal is to make men healthier and feel and function better.

In terms of testosterone levels, we aim to be in the high normal range.  It is unclear what level of testosterone is “too much.”  However, we have found that most men feel better at higher normal levels rather than mid-range levels.

When Will I Notice Any Changes from Testosterone Replacement Therapy (TRT)?:

Most men will not notice any changes for the first couple of months on TRT.  (The exception is that many men will notice an increase in the frequency and rigidity of morning erections relatively soon after starting.)  

Many men come into their one month visit, convinced that they do not have an increased level of testosterone. Some of these men may be right, because, for example, the topical testosterone treatments may not be giving them good blood levels of testosterone.  However, many men will have excellent levels, but not feel any different.

A few men will actually feel almost euphoric after beginning treatment.  We get calls from men exclaiming that “I feel 18 again!!!!”  However, it is not possible for this last.  Their body gets used to this higher level, and though they feel better than they did before, they will not continue to feel 18 forever.

In terms of symptoms, most men will notice:

Increased Muscle Mass and Energy- at 4 months

Improved Erections- at 6 months

Increased Libdio- at 9 months.

Of course, every man is different, but we strongly feel that before beginning TRT, you should mentally commit to getting excellent levels for a year.  We see many men who have tried TRT, but inadequately.  They either do not get excellent levels, or do not stay on it for long enough, or usually both.  They come in saying that TRT does not make a difference for them.  Of course it doesn’t, if they haven’t gotten or stuck with proper treatment.

For about 90% of our men who get excellent hormone levels, and stay on their regimen for a year, TRT is a true game-changer, and they notice fairly dramatic changes.   Again, every decision in medicine is a risks versus benefits one, and in the case of TRT is fairly easy to make!

More Information About Male Hormones or Androgens

Andropause is identified as a drop in androgens, the overall grouping of male hormones. They are made in the testes and in the adrenal gland (a small gland located above the kidney that produces a significant number of hormones). The main functions of androgens are:

  • Initiation and maintenance of spermatogenesis, the signal in a man’s body to produce sperm.
  • Determination, during pregnancy, that a fetus will be male.
  • Sexual maturation at puberty, controlling sexual drive and potency.

Relative Androgenic Activity of Adrenal Androgens  
Dihydrotestosterone 300
Testosterone 100
Androstenedione 10
DHEA, DHEA-S 5

In men, androgens are known to affect muscle, bone, the central nervous system, prostate, bone marrow and sexual function.

We know that testosterone causes “the androgenic effects,” determining and shaping the male reproductive tract in an infant as well as the development of secondary sexual characteristics (body hair and male pattern baldness are examples). In addition, androgens are responsible for prenatal differentiation of the male fetus and for the development of the male reproductive tract. Androgens play an important role in stimulating and maintaining sexual function in men. Testosterone is necessary for normal libido, ejaculation, and spontaneous erections.

Anabolic effects are those that promote growth. They affect other tissues such as muscle mass and bone density. Androgens increase lean body mass and affect body weight as well. Androgens are required to maintain bone density in men. It is still not clear whether the androgens are needed themselves to affect the bone or whether it is important that they be present so that when they are converted to estrogens, the estrogens have an effect on the density of the bones.

Androgens can affect red blood cell production and they appear to have an effect on blood fats and cholesterol. The most well-known effect of androgens is their effect on growth of the prostate. They affect both the non-cancerous and potentially cancerous cells in the prostate, but most likely after a man reaches a testosterone level of 300, additional testosterone plays no additional role.

Androgens also play an activating role in cognitive function throughout life, keeping men sharp and alert. The relationship between androgens and mood is still unclear, but in-depth exploration has begun.

Androgen Decrease

If you have andropause you may be wondering how you got it. Other factors may be contributors, but the primary one is that as men get older, their testes and adrenal glands don’t work as well. .

Other reasons are that the organs that produce testosterone just aren’t creating as much testosterone and more of that testosterone is being converted to other hormones like estradiol and DHT.

Testosterone

Specialized cells in the testis, called Leydig cells, make testosterone. As an adult male you produce about five grams of testosterone per day. You do this in bursts and there is a daily pattern, with a peak occurring early in the morning and a low point in the late evening.

Only certain cells in your body can receive the testosterone and a number of these cells later convert the testosterone into Dihydrotestosterone (DHT). DHT is three times as potent as the testosterone itself. Interestingly, the testosterone can also be converted into estrogens (the main female hormone). This occurs particularly in fat cells.

Most testosterone in the body is bound or “attached” to proteins. Thirty percent is bound to a type of protein known as sex hormone-binding globulin (SHBG). The testosterone binds very tightly to SHBG, which has a tendency to increase as men age. The remaining testosterone is bound much less tightly to other proteins in the blood, the most prevalent being albumin.

Two percent of the testosterone is unbound (not attached to any other protein) and is called free testosterone. Free and albumin-bound portions of testosterone make up the measure known as “bioavailable testosterone.” This is the testosterone that is seen in the tissue and that has the most effect on the body. So, any change will affect the total amount of available testosterone. The amount of SHBG, or blood proteins, also will affect the amount of available testosterone and will have an effect on the body.

What happens is that as you get older, your SHBG increases, meaning you have less available testosterone. Other hormones can affect SHBG, too. Elevated female hormones and thyroid hormones will increase SHBG, which will then, in turn, affect the bioavailable testosterone.

The symptoms that are associated with a loss of androgens may also be caused by decreases in other hormones, so testosterone replacement may not completely resolve all of the issues. However, at this point, there appears to be good evidence that testosterone replacement can improve many of these symptoms.

DHEA

Many of the active androgens in the body are not produced by the testes but by the adrenal glands. The major androgens created by the adrenal glands are DHEA, DHEA-S, and androstenedione. Although these androgens are not very strong, they are converted to the much stronger androgens: testosterone and DHT. However, they are a small percentage of the total androgens available in men. In men, the adrenal gland secretes approximately 3 to 4 mg of DHEA per day, 7 to 14 mg of DHEA-S per day, and 1 to 1.5 mg of androstenedione per day.

The adrenal steroid, DHEA-S, is the most plentiful steroid in circulation in the body. The amount of DHEA-S concentrated in the body is very dependent on age. Men have the most in their 20’s and 30’s. By his 70’s, a man’s DHEA-S level is down, on average, to twenty percent of its highest value.

While there has been a lot of research, interestingly, we still don’t know a lot about what DHEA-S does in the body. However, we think it has a “protective” role. It seems that the higher the DHEA/DHEA-S level is, the lower the incidence of cardiovascular disease and various forms of cancer, as well as many other aspects of cellular aging.

Growth Hormones

Growth hormone levels control the production of insulin-like Growth Factor 1 (IGF-1) that affects the body’s composition, lean body mass, and bone density. As growth hormones decrease, so does IGF-1. Growth hormone production decreases after puberty at a rate of approximately 14% every 10 years. This decrease in growth hormone is called somatopause (similar to the decrease in androgens being called andropause). It appears that administration of growth hormone can help improve body composition with increases in lean body mass and bone density.

However, little is known about the efficacy and safety of growth hormone.  There are studies that indicate it may increase the risk of diabetes and cancer.

In our practise, we will often check an IGF-1 level.  If it is normal, we do not treat with growth hormone.

Thyroid Hormones

The pituitary hormone that stimulates the thyroid to make thyroid hormones is called TSH. As men get older, TSH decreases and the thyroid becomes less responsive to TSH. What happens is that there is a decrease in the circulating amounts of thyroid hormones, and this may result in symptoms of hypothyroidism or decreased thyroid in the elderly. Decreased energy, metabolism and mental acuity are some of the symptoms. It is estimated that close to 20% of elderly men suffer from these symptoms.

We check TSH and free T3 levels in all men.  If TSH is elevated beyond 10, this is a clear indication that the thyroid is failing, and thyroid hormone supplementation should be started.  There is considerable controversy about whether to supplement men with thryroid hormone when their TSH is between 4 and 10.

If the active thyroid hormone levels are reduced, this is another indication for treatment.

Aging Male Symptoms Score (AMS)

Determining your Aging Male Symptoms Score (AMS) is a simple and effective way to detect whether you may have andropause. Based on a set of 17 factors, the score is designed to determine whether there is a general indication for andropause. If you are concerned that you may have andropause, simply score yourself using the form below. You can also download the Aging Male Symptoms PDF and score yourself, and take it with you when you visit your doctor. 

Each item is rated on a scale from 1 to 5; 1 representing an absence of symptoms, and 5 representing those that are extremely severe. Simply rate each item on the scale, then add up your score. There are 17 in total, so the minimum score is 17 and the maximum score is 85.

It’s important to keep in mind that having some of these symptoms isn’t necessarily an indication you have andropause. They could be related to some other cause, so a blood test is the best way to make a diagnosis.

The best way to complete the form is to not overthink each item. 


Symptom

1

None

2

Mild

3

Moderate

4

Severe

5

Extreme

Decline in your feeling of general well being (general state of health, subjective feeling)          
Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)          
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)          
Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)          
Increased need for sleep, often feeling tired          
Irritability (feeling aggressive, easily upset about little things, moody)          
Nervousness (inner tension, restlessness)          
Anxiety (feeling panicky)          
Physical exhaustion/lacking vitality (general decrease in performance, reduced activity, feeling of getting less done, of having to force oneself to undertake activities)          
Decrease in muscular strength (feeling weak)          
Depressive mood (feeling down, sad, on the verge of tears, mood swings)          
Feeling that you have passed your peak          
Feeling burnt out, having hit rock-bottom          
Decrease in beard growth          
Decrease in the number of morning erections          
Decrease in ability /frequency to perform sexually          
Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for intercourse)          

The implications of your score are as follows:

  • 26 or less means that you have no significant symptoms consistent with a low testosterone
  • 27-36 means that you have mild symptoms consistent with a low testosterone
  • 37-49 means that you have moderate symptoms consistent with a low testosterone
  • 50 or greater means that have severe symptoms consistent with a low testosterone

Thus we would suggest that if your score is 27 or greater your hormone levels be tested.