When men need testosterone replacement therapy

Testosterone is the principal male sex hormone, but research is showing just how many different conditions are affected by a drop in the production of this hormone.  The tricky part is establishing who needs Testosterone Replacement Therapy. Reader's Digest looks at the latest findings.

Testosterone is a principal androgen, or male sex hormone. Testosterone replacement therapy (TRT) has been shown to benefit men who suffer the symptoms of low testosterone. As well as decreased libido, low testosterone levels have been linked to health problems such as obesity, heart attacks and Type 2 diabetes.

Although TRT won’t counter the effects of a bad diet, lack of exercise and lifestyle choices such as drinking and smoking, it can have dramatic benefits. The downside of TRT is relatively small, given the potential benefits.

For one, the prostate must be monitored regularly for cancer. Rarely, testosterone injections and gels can cause overproduction of red blood cells, which thickens the blood and can lead to circulatory problems. 

Can testosterone restore the ageing male?

At 49, Martin Yalden was supposed to be in the prime of his life. His general health was good, he was within a healthy weight range, and his family life was better than ever. Why, then, was he lacking energy, and why was his mood constantly changing? “I felt tired, anxious, and had no energy,” recalls Yalden, who recently turned 60. “I had no libido, I was having night sweats, and my mood swings were uncontrollable – I had just lost all sense of balance.”

When his doctor couldn’t come up with a diagnosis, Yalden started doing his own research on the internet. Eventually, he came across the Testosterone Deficiency Centre, based in the UK, and sought advice from the centre’s online doctor. He was advised to consult an endocrinologist immediately and ask for a blood test to check his testosterone levels.

Yalden’s testosterone levels were much lower than average. But after exploring the different forms of testosterone replacement therapy (TRT), he saw dramatic changes almost instantly: he had a new surge of energy, he felt happier, and had a greater thirst for life. Over ten years later, Yalden, a car mechanic, has never regretted his decision to seek help.

The testosterone production decline

Testosterone levels decline gradually with age, about 1% a year after men reach the age of 40. At age 70, men generally have about half of what they had in their 30s. with less testosterone (a  condition also known as androgen deficiency), sexual function and motivation decrease, muscle mass shrink, fat deposits grow, bones lose density and are more susceptible to breakage, and the risk of developing type 2 diabetes rises.

Men with low levels of the hormone are also prone to other general symptoms, including low energy, mood swings, irritability and poor concentration – and are more likely to develop Alzheimer’s disease and to suffer heart attacks or strokes.

New research is promising

But for millions of men in their late 40s and older, the research looks promising: new evidence suggests that, for some men, returning testosterone to previous levels can help ward off medical problems including osteoporosis, heart attacks and depression.”Testosterone deficiency in the ageing male is one of the most controversial topics in men’s health,” says endocrinologist Dr Carolyn Allan.

While testosterone has been studied since the turn of the last century – and cyclically hailed and dismissed as a wonderful cure – Allan says the latest research indicates there are promising benefits of TRT on older men with severely low testosterone levels.

Indeed, part of the controversy today is the legacy of the junk science that promoted testosterone as a “cure” for homosexuality, frigidity in women and loss of make vitality. More recently, it has been linked to athletes and body builders who “juice up” with the hormone to increase muscle size and endurance.

There’s also anxiety around TRT because oestrogen replacement therapy has resulted in an increase incidence of cardiovascular disease and increased cancer risk in some women.

“Although oesrogen replacement therapy has been linked to an increased risk of cancer in women, there has been no research to suggest a link between testosterone replacement and the development of prostate cancer,” says urologist Dr Davis Malouf. “However, because it hasn’t been well studied, men with existing prostate cancer should avoid TRT, and those with a strong family history of prostate cancer should speak to their doctor before commencing it.”

TRT:  clinical deficiency is a requirement

Restoring testosterone levels can have remarkably beneficial effects. At the same time, Allan points out that TRT is warranted only when there are clear symptoms of testosterone deficiency: ”The symptoms are very non-specific, and that’s one of the difficulties,” she says.

“They relate to general quality of life; fatigue, poor concentration, memory loss, poor sex drive. But I’m always cautious when men talk about erectile dysfunction because that by itself is much more likely to be related to nerve and blood vessel function.”

Once TRT is justified, the patient can expect to be treated for life. Men need testosterone, regardless of age. “We may modify the level of treatment over time, based on the patient’s other medical issues, but if he has a deficiency, the assumption is that the treatment will be lifelong,” she says.

The difficulty with TRT is that it’s very much assessed on a case-by-case basis, as there are gaps in the research and difficulties in knowing what levels of testosterone should be considered “normal”. Generally, the healthier the older man, the more likely he is to have normal testosterone levels. Again, not all men will have a rapid decline in their testosterone levels. Many older men will maintain average levels of testosterone, as they get older, without the need of treatment at all.

However, if you are concerned, your doctor will be able to provide useful suggestions or refer you a specialist. Getting your testosterone levels checked is as easy as asking your doctor for a simple blood test – or two. As levels can fluctuate, a follow-up blood test is usually done for accuracy. If levels are low, the hormones can be replaced in several ways.

TRT: effective delivery options

The most cost-effective and reliable option is an injection every two-to-three weeks. However, not everyone wants to self-administer a shot or visit their doctor often. Another consideration is that, with injections, the medication effect is strong at first, then tapers off over a few weeks.

Other options include gels rubbed on the skin once a day; capsules (taken up to three times a day with fluid or fatty meals); and  skin patches (about one in five men develop a skin rash when using the patches, but this can be avoided by changing the patch’s location or using cortisone cream).

Some chemists may offer oral preparations (medical lozenges or troches), but these have not been fully researched.

Approaches may be a matter of personal choice, so if your testosterone levels found to be low, speak with your doctor about which TRT options may be best suited to you.

Online help on male health

The South African Sexual Health Association (sexualhealth.co.za) provides fact sheets on conditions such as low testosterone, erectile dysfunction and prostate problems

Read more:

Men and the mid-life slump

Visit the Man Centre for mens' health information

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