Written by Linda Yau, M.D., F.A.C.P.
May 13, 2014
Much controversy surrounds the concept of a possible male menopause. Dr. Kristen Gill Hairston, an associate professor in endocrinology from Wake Forest School of Medicine gave an excellent summary of the symptoms of low testosterone, medical evaluation and possible treatments at the ACP (American College of Physicians) annual meeting. She cautions that only patients who have both symptoms and a low blood level of testosterone should be treated with medication.
1) When should men think about the possibility of low testosterone causing symptoms?
a) Higher sensitivity sign and symptoms include:
- Incomplete or delayed sexual development
- Reduced libido and sexual activity
- Decreased spontaneous erections
- Breast discomfort
- Loss of body hair, reduced shaving
- Infertility
- Suffering a non-traumatic fracture
b) Less specific symptoms (many other conditions can cause these) include:
- Decreased energy, motivation or initiative
- Poor concentration or memory
- Mild anemia (low red blood cell count)
- Sleep disturbance
- Feeling depressed or sad
- Reduced muscle bulk
- Diminished physical or work performance
Speak with your physician if you have the symptoms above and determine if it is appropriate to take a blood test to check testosterone levels.
2) What are the next steps in evaluating possible testosterone deficiency?
To evaluate for testosterone deficiency, the next step is to have at least 2 morning blood draws for total testosterone. If the testosterone level is less than 300, the recommendation is to repeat it to confirm the level. The physician should exclude other illnesses that cause low testosterone such as low thyroid levels, outside medication effects such as steroid use, and also realize that moderate obesity can lower testosterone. If the testosterone level remains low, the LH (luteinizing hormone) and FSH (follicle stimulating hormone) should be drawn to evaluate whether the issue lies in the pituitary gland versus the testicles.
3) What are the options for treatment?
There are intramuscular injections that are given every 3 weeks which are the least expensive of the options and frees patients from daily administration. These are usually given in a urologist’s office. The disadvantage is that there are peaks and troughs compared with the daily medication, and the patient needs to go in to get a shot. Testosterone administration comes in gels which the patient puts applies to the upper chest daily. It comes in packets and pumps. Common trade names are Androgel, Testim, and Axiron. Caution should be taken to only place the gel where a short sleeved shirt would cover it to avoid transferring the medicine to someone else. Patients should wait 5 hours before showering, swimming or bathing. The gel is flammable until dry, so avoid any fire if the gel is wet. Testosterone also comes in daily patches. About 20% of patients get a rash or skin irritation with patches.
4) Who should not use testosterone replacement?
Patients who have either prostate or breast (yes, men can get breast cancer!) should not use testosterone as testosterone can fuel those types of cancers. Those with congestive heart failure or untreated sleep apnea should not use testosterone as replacement can worsen those conditions. Testosterone may increase the PSA (prostate specific antigen) and the red blood cell level (hemoglobin and hematocrit), so patients who have an already elevated PSA, prostatic hypertrophy , or an elevated red blood cell level (hematocrit over 50%) are advised not to take it. Patients who have a history of blood clots should avoid testosterone replacement, as the medication can increase the risk for developing a blood clot.
5) What type of monitoring is needed while taking testosterone?
All men who use testosterone replacement should have their testosterone, complete blood count (CBC) and their PSA checked 3 months after starting the medication. If all is fine, those levels can be checked again yearly after the first 3 months. Serum testosterone should be checked at the midpoint between injections or 3-12 hours after applying a new patch. For those who use the gel, the blood level can be checked at any time. The prostate exam should be done 3 months after the testosterone is started to make sure the prostate is not severely enlarged or developed a nodule.
In summary, testing for low testosterone should only be done if a man has signs or symptoms of the syndrome. The diagnosis then should only be made in those with symptoms and unequivocally low testosterone levels (less than 300 mg/dL ) on more than one occasion and drawn in the morning. Symptoms should improve with testosterone replacement. Lab tests and the prostate exam should be checked 3 months after starting treatment and yearly thereafter.
References:
1) Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline http://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Practice%20Guidelines/FINAL-Androgens-in-Men-Standalone.pdf
2) Nazem Bassil, Saad Alkaade, and John E Morley The Benefits and Risks of Testosterone Therapy: A Review, Ther Clin Risk Manag. 2009; 5: 427–448
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701485/
FDA Medication Guide to Testosterone Gel: http://www.fda.gov/downloads/Drugs/DrugSafety/UCM294248.pdf