Men, Testosterone, and Andropause

My hope is that more men will feel empowered to learn more about low testosterone and, if they are experiencing symptoms, to seek diagnosis and treatment.

Compared with men who used placebo gel, researchers at the New England Journal of Medicine found that those who used the testosterone gel experienced significant improvements in all areas of sexual function - including sexual desire, sexual activity and the ability to get an erection.

© Jostein Hauge |

Before I began working as a writer and editor for Natural Health Advisory Institute—when I was seeing patients full-time—I saw men in my office every week with classic symptoms of low testosterone. All too often, their physicians dismissed their complaints. Sometimes, my male patients would come with test results for low testosterone, as well as symptoms, but their physicians misinterpreted those test results or just didn’t feel comfortable prescribing testosterone. Still other patients of mine weren’t even aware of just how bad they felt and how many symptoms of low testosterone they were actually experiencing—until, that is, a few months into testosterone therapy—when they would exclaim, “I can’t believe how much better I feel!”

Although that was just a few years ago, the climate has fortunately changed. There is increasing awareness and willingness on the part of physicians to diagnose and treat low testosterone. This month’s top story provides a brief overview of age-related low ­testosterone in men. My hope is that more men will feel empowered to learn more about low testosterone and, if they are experiencing symptoms, to seek diagnosis and treatment.

The male version of menopause—often referred to as andropause—is real. When men are in their 30s, testosterone secretion by the testes begins a slow decline.1,2 The process is individually highly variable and, in contrast to menopause, very gradual. Low testosterone symptoms in men may be dramatic or almost imperceptible, especially at first. Eventually, however, all men will experience the deleterious effects of age-related testosterone decline.

Sexual symptoms of low testosterone

Although the conventional medicine framework recognizes the wide range of symptoms of low testosterone, most conventional medical guidelines rely on a very limited set of low testosterone symptoms for diagnosis and treatment. Called late onset hypogonadism, these all relate to impaired sexual function: low libido, erectile dysfunction, and decreased morning erections.3

Conventional guidelines require that a man have serum levels of total testosterone below 300 ng/dL and the presence of all three sexual symptoms to be treated.3

However, low testosterone levels can cause a multitude of problems beyond these sexual symptoms. It can lead to declines in physical, mental, and emotional health, which can profoundly affect a man’s well-being. Many of the signs and symptoms of low testosterone are nonspecific and can be different depending on the man’s age, whether he has any other health conditions, how low his levels are, and how long they have been low.

Additional symptoms

Besides the sexual symptoms, low testosterone symptoms in men include the following:3-9

  • Breast discomfort and/or enlargement
  • Loss of body hair, reduced shaving
  • Height loss, low bone mineral density
  • Hot flushes, sweats
  • Decreased energy, motivation, initiative, and self-confidence
  • Feeling sad or blue, depressed mood, clinical depression
  • Irritability
  • Anxiety
  • Poor concentration and memory
  • Fatigue
  • Sleep disturbance, increased sleepiness
  • Reduced muscle mass and strength
  • Increased body fat, body mass index
  • Diminished physical or work performance
  • Heart disease and diabetes risk factors: high blood pressure, low HDL-cholesterol, increased waist circumference, high blood glucose, high triglycerides

Long-term dangers of low testosterone

Age-related testosterone decline is associated with an increased risk of death due to all causes, independent of several risk factors and pre-existing health conditions.10,11 It is also associated with an increased risk of death due to cardiovascular disease12 and with the development of many chronic conditions, including:

  • Heart disease and strokes13
  • Metabolic syndrome9,14
  • Cognitive impairment and dementia15
  • Osteoporosis and fractures16

Measuring testosterone

While not every man’s testosterone levels will fall below normal as he ages, almost 40% of men over age 45 have abnormally low serum total testosterone levels—below the lower limit of the reference range of adult men (300 ng/dL or 10.4 nmol/L).17 Although some men with levels below this threshold have no noticeable symptoms of testosterone deficiency, many do.

Other men may have symptoms of low testosterone even if total testosterone levels are above this threshold. This is because too much of their total testosterone is locked up and bound to a protein known as sex hormone binding globulin (SHBG). Testosterone bound to SHBG is permanently unusable by the body. Normally, about 70% to 80% of total testosterone is bound to SHBG. The older or more overweight a man is, the more SHBG he makes, and the more his total testosterone is locked up, unusable by his tissues.18

Fortunately, serum total ­testosterone is just one of many ways to measure testosterone. It’s now easy and common to measure free and bioavailable testosterone. Free testosterone, which makes up 1% to 2% of total testosterone, is not bound to anything and is immediately available for use. Bioavailable testosterone, which makes up around 20% of total testosterone, is weakly bound to albumin, a protein from which it can easily detach and become free. Knowing your serum free and/or bioavailable testosterone concentrations tells you exactly how much of the total testosterone is not bound to sex hormone binding globulin and is thus usable by the body.

With age (and weight gain), less and less of a man’s total testosterone is free and bioavailable.18 Serum free and/or bioavailable testosterone levels may be low even if total testosterone levels are within the normal range.18 Men in this situation may still benefit from testosterone therapy.19 It’s therefore important to measure free and/or bioavailable testosterone levels, especially in men in whom total testosterone concentrations are near the lower limit of the normal range.

Testosterone replacement therapy

Treatment with testosterone replacement therapy increases testosterone levels and decreases symptoms of low testosterone in men, including physical, mental/emotional, and sexual symptoms.3 Overall, testosterone therapy improves vitality and quality of life for most men with symptomatic testosterone deficiency. Testosterone replacement therapy leads to a variety of benefits:3,20-24

  • Improved mood
  • Increased energy levels
  • Improved quality of life and sense of well-being
  • Improved body composition (decreased weight, fat mass, and waist circumference; increased muscle mass and strength)
  • Improved bone density
  • Improved libido and erectile function
  • Lower total and LDL cholesterol, higher HDL cholesterol
  • Lower triglycerides
  • Lower blood pressure and improved blood vessel functioning
  • Reduced inflammation
  • Lower blood glucose and increased insulin sensitivity

Bioidentical testosterone

Many forms of testosterone therapy are available, including oral, topical (gels, creams, patches), sublingual, implantable pellets, and injections. Some of these therapies use natural, bioidentical testosterone, while others are synthetic pharmaceutical drugs that closely resemble testosterone but have been altered for patentability and other reasons.

Practitioners of natural, integrative, and anti-aging medicine tend to prefer bioidentical forms of testosterone over the synthetic drugs that mimic testosterone. Bioidentical—or human identical—hormones are made to exactly match human hormone chemical structure. In contrast, synthetic hormone-like drugs are distinctly different compounds in terms of their chemical structure, pharmacology, and effects in tissues.

Topical testosterone in the form of bioidentical testosterone gels or creams is the most commonly used form of testosterone. Either compounded at compounding pharmacies or, nowadays, made by large pharmaceutical companies and sold as brand-name drugs (like AndroGel or Testim), topical, bioidentical testosterone can be formulated for steady absorption into the bloodstream to avoid swings in blood levels. Topical bioidentical hormones more closely mimic the body’s natural hormone secretion and have advantages in terms of safety and efficacy.25,26 Bioidentical testosterone can be formulated by compounding pharmacists into topical creams, gels, sublingual tablets, and other delivery forms in dosages to mimic normal, physiologic levels. The pharmaceutical company’s products are typically more expensive and are only available in limited dosages. Some have synthetic fragrances added.

Oral testosterone is rarely used as it is mostly inactivated by the liver before it enters the circulation and can cause significant liver injury.

Injectable bioidentical testosterone is not used because it leaves the body too quickly. Injectable forms of synthetic, testosterone-like drugs have been chemically altered to last longer in the body. However, they have been found to cause large swings in testosterone levels that cause side effects in many men.

Risks of testosterone therapy

Testosterone therapy, whether conventional or bioidentical, does have some potential risks that must be considered. One of the main concerns with testosterone replacement is that, in theory, it has the potential to increase the risk of hormone-related cancers such as prostate cancer. However, in practice, testosterone replacement therapy has never been shown to increase the risk of developing prostate cancer or lead to its progression.21,27 Nevertheless, regular monitoring of PSA (prostate-specific antigen) is recommended for all men using testosterone.

Another primary concern with testosterone therapy is that of cardiovascular disease risk. Although two studies raised some concerns regarding cardiovascular risks with testosterone therapy, a recent article published in Mayo Clinic Proceedings reviewed those studies as well as the extensive literature and concluded that, “…there is no convincing evidence of increased cardiovascular risks with testosterone therapy. On the contrary, there appears to be a strong beneficial relationship between normal testosterone and cardiovascular health.”28

What to do if you think you might have a testosterone deficiency

Most conventional doctors do not recommend bioidentical testosterone because they have never been trained to safely administer it. If possible, work with a doctor who carefully insists on only using the bioidentical version of testosterone. Make sure he or she has received training in bioidentical hormone replacement therapy and also has extensive experience in treating patients. Bioidentical testosterone is best administered in individual customized dosages based on blood testing. Your levels need to be continually monitored by your physician.

To find a knowledgeable doctor who can do all the blood testing and monitoring necessary, and who factors in symptoms as well as lab results in making a decision on testosterone replacement, use NHA’s Provider Directory or the A4M Anti-Aging Directory or the American College for Advancement in Medicine’s Directory.

Certainly it is good news to know that men who have one or more of the symptoms described here and whose lab work shows low testosterone levels now have an alternative that is both safe and effective. If that applies to you, seek out one of these skilled physicians who can administer bioidentical testosterone and see if that doesn’t improve your quality of life like it has done for many others.

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24. Steroids. 2014 Oct;88:117-26.
25. Expert Opin Pharmacother. 2010 Jun;11(9):1489-99.
26. Int J Pharm Compd. 2013 Jan-Feb;17(1):74-85.
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28. Mayo Clin Proc. 2015 Feb;90(2):224-51.

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