Learn about the symptoms of low testosterone and how testosterone replacement therapy can help.

Testosterone, the androgen hormone or “steroid” that makes men masculine, is a frequent concern for aging men and men with symptoms of decreased sexual function and low energy. Low T in adult men was often called andropause or androgen deficiency of the aging male (ADAM), but is now more frequently referred to as hypogonadism or testosterone deficiency syndrome (TDS). The treatment of low T has grown significantly over the past decade as a result of newer medications that normalize testosterone in those men with low levels.

Testosterone is produced mostly in men’s testicles and increase during adolescence to create an adult, masculine appearance and function. Testosterone is important for a man’s development, sperm production, sexual function and normal male appearance including muscle development, pubic hair and voice changes. Testosterone production is controlled by hormones in the pituitary gland of the brain. Testosterone continues to rise until the 30s when it begins to decline throughout aging, about 1 percent each year.

The signs of low T in men are often subtle and can be missed by both patient and doctor. These signs and symptoms include low interest in sex, decreased erections along with depression, low energy, fatigue and osteoporosis. While any man may suffer low T, men at highest risk for this condition includes men with diabetes or erectile dysfunction, men who take chronic opiate pain medications, and men who have stressed, chronic diseases (such as AIDS, COPD or cancer). Men with significant depression are also frequent sufferers of low T.

How is low T diagnosed?

Doctors make the initial suspicion of low T by asking the patient about symptoms and high risk conditions. The definite diagnosis is confirmed by a combination of symptoms and a blood test for serum testosterone, taken in the morning. Tests for hormones of the pituitary and circulating proteins that inactivate testosterone may also be evaluated. If the symptoms and blood tests confirm low T and the doctor feels that testosterone replacement therapy is needed and safe, there are many agents that can restore the T to normal levels. Once treatment begins, it is usually a long-term commitment, and careful monitoring is essential. The clinical guidelines suggest regular evaluation of the testosterone levels, blood count and a PSA for checking prostate effects of the testosterone.

Treatment options include: topical gels applied each morning, weekly or biweekly injections, testosterone pellets placed in the buttocks every three months, long-acting injections repeated every 10 weeks and a nasal formulation. Unfortunately, a convenient and safe pill for testosterone is not available in the U.S., although there are several under development.

Is T replacement safe?

The goal of testosterone replacement is normalizing testosterone levels so that they are equivalent to those of the average healthy man and to eliminate the symptoms caused by a low T. While there is controversy about the diagnosis and treatment of low T, for most men carefully diagnosed with low T and treated appropriately, testosterone is a safe treatment alternative and often changes men’s lives by restoring energy, vitality and strength as well as interest in sex. Several studies suggested that testosterone replacement may have cardiovascular risks while many others suggest a long-term benefit to normalizing testosterone.

Studies of survival from all causes of death have suggested an advantage for those men with normal testosterone, whether it’s from their own production or from testosterone replacement. Similarly, studies have shown an advantage to normal testosterone for sexual function, diabetes control and improved obesity control.

Conventional wisdom has suggested a risk for testosterone replacement and the prostate. In fact, many doctors believe that prostate cancer and symptoms of prostate enlargement called benign prostatic hyperplasia (BPH) can be caused by testosterone replacement. While the development of the prostate in adolescence is dependent on testosterone, there is no evidence that prostate cancer is caused or made worse by testosterone replacement. Similarly, testosterone replacement may, in some men, lower sperm counts. If men are considering children, other methods for normalizing T should be considered.

The message is, however, that for men who are frail, elderly or diagnosed with heart disease, testosterone replacement may not be advised. For other men suffering from low T, testosterone replacement may improve their lives remarkably and is a safe treatment.

Culley C. Carson III, MD is the John Sloan Rhodes and John Flint Rhodes Distinguished Professor of Urology at the University of North Carolina at Chapel Hill. He received his MD from George Washington University School of Medicine in Washington, D.C., followed by a residency in surgery at Dartmouth-Hitchcock Medical Center in Hanover, NH, and a residency and fellowship in urology at the Mayo Clinic in Rochester, MN. He is board certified in urology. Dr. Carson has authored or co-authored more than 500 books, book chapters, and articles published in peer- reviewed journals.