Testosterone deficiency
What is testosterone deficiency?
Testosterone deficiency, also known as hypogonadism, is a condition in men where the body produces much less testosterone than would be expected. [1]
Testosterone is a hormone produced in the testes and it is important in maintaining overall health. When levels are very low, men experience a number of physical and psychological symptoms as a result. [1]
Symptoms may include
- Impact on sexual function including erectile dysfunction, difficulty maintaining or getting an erection or decreased sex drive
- Extreme tiredness (fatigue)
- Mood changes including increased irritability and anger and generally feeling less content with life
- Decreased ability to exercise and lack of energy
- Presence of anaemia
- Decreased strength
- Weight gain
Symptoms
Testosterone plays an integral role in the maintenance of overall health and deficiency leads to the development of a spectrum of clinical symptoms
Recognising the signs and symptoms of clinically relevant testosterone deficiency and hypogonadism is of significant importance. Research indicates that a large portion of men with the condition are undiagnosed and subsequently left untreated. [4]
The EAU guidelines group the major signs and symptoms of hypogonadism into clinical signs and symptoms, sexual symptoms and cognitive symptoms. [4]
Causes and risk factors
Testosterone deficiency may develop as a result of normal aging. [5]
It is expected that 40% of men over the age of 45 and 50% of men over the age of 80 are testosterone deficient[5] so the condition is very common and likely underreported. [5]
However, there are several risk factors and comorbid conditions (conditions which you may be diagnosed with alongside hypogonadism) which may mean you are at a higher risk of developing the condition which include: [4]
Learn more about the impact of testosterone deficiency.
Trauma or injury
Exposure to environmental toxins
Infection causing damage to the prostate or to the regulatory axis which may be bacterial or viral
Malignancy, either directly from development of cancer in the prostate or from the subsequent treatment which may involve administration of therapeutics or radical prostatectomy
Obesity
Genetic risk factors such as Klinefelter syndrome and Kallmann syndrome
Diagnosis
In order to make a diagnosis, your doctor will need to assess your physical symptoms and carry out some biochemical tests
1
History taking and questionnaires
Firstly, you will be asked a series of questions about your wellbeing and overall health. This is to determine if you have any of the signs and symptoms of testosterone deficiency.
2
Physical examination
If you do, your doctor will order for you to have a simple blood test to measure the amount of testosterone in your blood and determine if this is out of the normal range. [3]
3
Laboratory diagnosis
Both presence of symptoms and a confirmation through a blood test are required to be diagnosed.
Treatment options
Testosterone deficiency / hypogonadism is treated with testosterone replacement therapy, also referred to as TRT.
TRT involves prescription of a testosterone formulation which patients take to increase the amount of testosterone in their body. There are multiple different formulations available which differ on how they are administered. The prescribing clinician will make a decision based on the patient and their needs as to which formulation they think will work best for them.
Types of formulation and routes of administration include: [6]
Testosterone gels
Testosterone gels are administered by applying them to the skin usually once daily which allows absorption into the bloodstream. This is a popular formulation as the gels absorb quickly, are easy to use and are not associated with many side effects. [6] They also allow patients to take the medication in the privacy of their own home and remove the need to have to see a doctor to have medication administered. [6]
Buccal tablets
It is unlikely that TRT will be prescribed in the form of an oral tablet as it is difficult for the body to absorb testosterone in this way. [6] However, there are some oral adhesive patches available which are placed on the gum allowing testosterone to absorb directly into the bloodstream from there. [6]
Intramuscular injection
TRT may also be administered by an intramuscular injection. This route of administration demonstrates good uptake of testosterone by the body but does require the patient to attend appointments with their clinician to have the medication administered which may work well for some patients but not for others. [6]
There are other options for TRT available but these are the most commonly used in routine practice. Each type is available as multiple different brands and different formulations, and the prescribing clinician will be able to advise on what they think is the best option for you.
Precautions and concerns
Prostate cancer concerns
There was initially some concern that TRT could cause the development of prostate cancer. However, through extensive research we now know that this is not true and taking TRT will not increase your risk of getting prostate cancer. [7]
However, if you have untreated prostate cancer, you will not be treated with TRT as a precautionary measure in case the treatment should stimulate further growth of the cancer. [3]
Cardiovascular concerns
Men have an increased risk of poor cardiovascular health so the impact that TRT on heart health has been investigated. It has been concluded that TRT does not cause an increased risk of cardiovascular events, but TRT will not be prescribed if you have severe chronic heart failure as it may make the existing condition worse. [3]
Other concerns and considerations
As TRT impairs sperm production, your doctor will likely ask you if you are planning to have children in the near future before you are prescribed TRT. [3]
TRT will also not be prescribed in cases of a rare male breast cancer. [3]
TRT may also not be prescribed to those who have severe untreated sleep apnea and if you have elevated prostate specific antigen (PSA) levels, further consultation with other health specialists in the field of urology may be required before TRT can be initiated. [3]
If you have any concerns over suitability for TRT or the safety of the therapy, please speak to your doctor.
References
1. Salonia A, et al. Nat Rev Dis Primers. 2019 May 30; 5(1): 38.
2. Dohle G et al. EAU Guidelines on Male Hypogonadism 2018. Available at: http://uroweb.org/guideline/male-hypogonadism/. Accessed date: December 2021.
3. Hackett G, Kirby M, Edwards D, et al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. The journal of sexual medicine. 2017;14(12):1504-1523.
4. Kumar et al. J Adv Pharm Technol Res. 2010 Jul-Sep; 1(3): 297–301
5. Omeed & Schwartz. Treasure Island (FL): StatPearls Publishing; 2021.
6. Shoskes, Wilson & Spinner. Transl Androl Urol. 2016 Dec; 5(6): 834–843.
7. Khera et al. Eur Urol. 2014;65(1):115-23. doi: 10.1016/j.eururo.2013.08.015
* Particularly those which are opioid based. PSA = prostate specific antigen, TRT = testosterone replacement therapy.