Testosterone deficiency

WHAT IS THE 'ANDROPAUSE'?

Andropause is a decline in the male hormone testosterone. This drop in testosterone levels is considered to lead in some cases to loss of energy and concentration, depression, and mood swings.

While andropause does not cause a man's reproductive system to stop working altogether, many experience bouts of impotence. Andropause is usually caused by a very gradual testosterone deficiency and an increase in sex hormone-binding globulin (SHBG) that occurs from age 35 onwards.

TESTOSTERONE DEFICIENCY SYNDROME 

How common is Testosterone Deficiency Syndrome (TDS)?

AndropauseTestosterone Deficiency is common in older men, so if you do suffer with low testosterone don't worry, you are not alone! In fact, it has been estimated that up to 1 in 10 men over the age of 50 – increasing to 1 in 5 over 60 – have TDS and have testosterone levels below normal.

As we age, our bodies do not function as well as they did when we were younger, and in men it is expected that testosterone levels will decline with age. However, it is important to note that this is different from TDS where testosterone levels fall below normal. So do remember that TDS is a recognized medical condition and should NOT be considered as an inevitable consequence of ageing.

It is particularly common in type 2 Diabetes with approximately 1 in 3 men suffering from it.

Testosterone plays a number of important roles in men. For example, this hormone influences aspects of our short-term health like mood and sex drive, as well as being important to our long-term health by helping to maintain strong bones and a healthy body shape.

How do I know if I have Testosterone Deficiency Syndrome (TDS)?

It is important to remember that there are many different signs and symptoms associated with testosterone deficiency and these can vary between different men. The list below shows examples of the signs and symptoms commonly associated with it.

Again, please remember that if you do suffer with one, or some of these symptoms, it does not mean that you definitely have TDS – other illnesses can cause the symptoms. Our doctor is the best person to confirm whether you have low levels of testosterone by measuring it. When talking to your doctor or nurse it is important to remind them of all your current and previous illnesses and medications – because these may be related to low testosterone levels.

Low mood (feeling depressed)

Poor circulation

Unusual or excessive tiredness/lack of energy

MIND

Reduced muscle mass and/or strength

Increased body fat

Osteoporosis (‘brittle bone disease')

Anemia (low levels of red blood cells)

BODY
Reduced sex drive – possibly with erection problems SEXUAL FUNCTION

How is my testosterone level measured?

Measuring your testosterone level is quick and simple. You will have to give a small blood sample (usually in the morning) from which your testosterone level can be measured.

Will I need any other tests?

This will depend upon your doctor, your symptoms and your medical history. For example, as well as measuring your testosterone levels, some doctors may also use a questionnaire to help assess whether you are suffering with TDS. Additionally, there may be other aspects of your health that may need further examination – like the health of your bones or prostate (a small gland near your bladder).

What treatments are available for TDS?

There are now many different treatments available for TDS. Treatment that replaces the body's levels of testosterone is referred to as Testosterone Replacement Therapy (TRT) and the different ways in which TRT can be administered currently include oral, inject able and topical therapy. The most popular being a gel which you apply once a day to your skin. This gel can be purchased or prescribed by the clinic.

If you are suffering with health problems as a result of low testosterone, then restoring your level to normal will improve your short-term and long-term health.

Clomiphene Citrate (Clomid)

Very effective in increasing levels of testosterone in the younger patient without reducing sperm production or causing shrinkage of the testicles.

How does it work?

Clomid is a weak oestrogen receptor antagonist, it blocks the normal negative feedback mechanism of circulating oestradiol on the hypothalamus, preventing oestrogen from limiting the production of GnRH. The increase in GnRH level then stimulates the pituitary gland to release more FSH and LH, resulting in an increase in sperm and testosterone production by the testes.

Results

Most patients respond to the treatment. Recent study from Brazil showed a response rate of 68% with the only side effect being nipple tenderness in 5% of patients. In this study the average age of the patient was 62. It is clear that the best responses occur in the younger patients.

Side effects

Occasionally nipple tenderness.

Very rarely visual changes may occur which are reversible with discontinuation.

Is Testosterone Replacement Treatment completely safe?

No medication can be said to be 100% safe and effective. However, provided certain precautions are taken, like checking that your Prostate Specific Antigen (PSA) is normal then Testosterone Replacement Therapy is very safe and well tolerated.

I have heard that Testosterone treatment can cause cancer of the prostate. Is this true?

No, testosterone treatments do NOT cause cancer of the prostate or of anything else for that matter. Prostate cancer occurs in older men with very low testosterone levels and is rare in younger men with high levels. But where prostate cancer already exists, giving testosterone in this situation might serve to accelerate its growth. This is why keeping a close eye on PSA is essential for any many on TRT.

Are there any ‘fringe benefits’ to taking TRT apart from the sexual ones?

Yes. Apart from improving you sexually there are a number of potential benefits that are now beginning to emerge for men who have been taking TRT long-term. Among these are:

Improvements to your cardiovascular system

Improvements to your cognitive function and memory

Increased mineral bone density to help against fractures

Increased muscle mass and decreased body fat.

All that said it is a mistake to expect miracles. The benefits from TRT are often subtle and mild and not life transforming but rather life enhancing.

CASE STUDY: DO YOU HAVE LOW TESTOSTERONE?

AndropauseDebbie Wood realized her husband Kerry had a problem the day she married him in 1991. “He was totally uninterested in sex and would make every excuse possible to get out of it,” she says.

“It was’t that he could’t perform – he just did’t want to. We only had sex once or twice a year and he just did it to keep me quiet for a few months.”

Unsurprisingly, Debbie, now 44, began to believe that her husband didn’t love her. “It was a constant cause of arguments. By the time we hadn’t had sex for two years, I made him go to the doctor. It was that, or get a divorce.”

Kerry, 50, had a blood test to rule out diabetes, was prescribed antidepressants and was sent for relationship counseling, but nothing helped. It was only when he was referred to a specialist at the Leger Clinic in Doncaster 15 months ago that testosterone deficiency syndrome (TDS) was correctly diagnosed.

Debbie says: “Within three weeks of using a testosterone gel he was a different fellow. He had more energy. We have a normal married life now.”

Although lack of sex drive and energy are common and important symptoms, TDS is also a potentially life threatening condition. Men with a low testosterone are more likely to develop central obesity, insulin resistance, poor glucose control, high blood pressure and abnormal cholesterol levels.

This combination of symptoms and signs (known as Metabolic Syndrome) greatly increases your risk of Type 2 diabetes and of having a heart attack or stroke. In fact, if you have an untreated low testosterone level, you are 68 per cent more likely to die prematurely, from any cause, than a similar man with a normal testosterone level.

Lack of testosterone is surprisingly common. It’s a fact of life that male testosterone levels naturally fall by around one per cent per year from middle-age onwards.

Men aged between 40 and 80 have a one in eight chance of having symptoms due to TDS.

The risk is greatest in men with erectile dysfunction (one in five), and in those with Type 2 diabetes, two out of five of whom are affected.

If the problem is correctly diagnosed, testosterone replacement therapy can improve nearly every aspect of life – and has the potential to prolong it.

Bringing testosterone levels back up into the normal range improves glucose control and cholesterol balance, as well as energy levels, sleep quality and mood.

It also increases muscle mass and bone strength while helping you to lose weight – especially around the waist.

It boosts the libido – usually within four to six weeks of starting treatment. Having a normal testosterone level also increases the chances of a good response to drugs such as Viagra, Levitra or Cialis.

Treatment options are improving all the time. As well as implants, injections, patches and a tablet that dissolves in your mouth, the mainstay of treatment is a testosterone gel.

A more concentrated version called Tostran was launched earlier this month by ProStrakan, a pharmaceutical company based in Scotland. The gel is applied to the abdomen or inner thighs, once a day, and acts as a reservoir from which testosterone absorbs through the skin at a constant rate.

Tostran is being used as part of a large-scale European trial called TIMES2. Researchers designed the trial to understand more about the benefits of testosterone treatment on insulin resistance and blood glucose control in men with metabolic syndrome or Type 2 diabetes.

Unfortunately, many men – and some doctors – remain unaware that testosterone deficiency is such a common and serious condition.

“I didn’t know I had a problem,” says Kerry. “I just thought I had a nagging wife.

“I can’t help thinking how different much of my life would have been if I’d only known. I feel more in control, more confident, more positive and relaxed. It saved my marriage.”

Testosterone deficiency in the younger patient

I am seeing an increasing number of young apparently ‘healthy men’ with symptoms of low testosterone and borderline levels – i.e. below 12 nanomoles per litre but not as low as 8 which has traditionally been the level that doctors will recognise the problem and proceed to treat.

I sadly see many young men who have been diagnosed incorrectly as suffering from stress or depression as a cause of their symptoms, when the problem is actually due to testosterone deficiency.

One of the main problems is when a GP orders a blood test. The ‘normal’ range is given as 8-30 nmol/L by the lab, this is without any mention of age or symptoms, therefore making it likely that the patient will be ‘dismissed’ as having a normal level. This is despite the fact that there are now several guidelines including the latest which has just been revealed from the International Society of Sexual Medicine which states that a level between 8-12 warrants a ------ of treatment.

In the younger patient I would normally recommend Clomiphene treatment (see information on Clomiphene in the treatment section of the website).

For many men with symptoms of testosterone deficiency confirmed by low levels- under 12, it is not always clear why this occurs, but of course I will search for plausible causes through the use of my medical history taking examination and also relevant blood tests.

I actually believe that testosterone deficiency- like underactive thyroid is quite common condition and as we say, common things occur commonly.

TIME FOR A CHECK-UP?

IF you are over 40, try the ADAM (androgen deficiency in ageing males) questionnaire:

1. Do you have a decreased libido (sex drive)?

2. Do you suffer from lack of energy?

3. Have you noticed a decrease in strength and/or endurance?

4. Have you lost height?

5. Have you noticed a decreased “enjoyment of life”?

6. Are you often sad and/or grumpy?

7. Are your erections less strong than they used to be?

8. Have you noticed a recent deterioration in your ability to play sports or exercise?

9. Do you find yourself falling asleep after dinner?

10. Has there been a recent deterioration in your work performance?

If you answered YES to questions one or seven, or any three other questions, you may have testosterone deficiency syndrome. Talk to your GP because you may need to have your testosterone levels checked.

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