Primary hypogonadism, or testicular failure, is a condition where the testicles do not make enough testosterone. Secondary hypogonadism occurs when the brain (pituitary and/or hypothalamus) do not send appropriate signals (luteinizing hormone, LH) to the testicles telling them to make testosterone. Acquired hypogonadism refers to low testosterone related to aging.
As in all medical conditions, evaluation begins with an appointment where your urologist can take your medical history, perform a physical exam, and order appropriate blood tests.
In a male with symptoms of Low-T, a testosterone level can easily be measured with a simple blood test. Testosterone levels naturally fluctuate during the day and peak in the morning between 7 and 9am. For this reason, it is best to measure a testosterone level in the early morning. A normal testosterone level is between 300 and 800 ng/dl. Other lab tests that may get ordered include a prolactin, LH (luteinizing hormone), FSH (follicle-stimulating hormone), complete blood count, and PSA (prostate specific antigen).
There are many options for the management of Low-T:
- Transdermal gels are ointments or gels that the patient applies to their skin once every day. There are many different formulations of these available. The patient must avoid skin to skin contact with females and children after application.
- Injectable testosterone is a shot that the patient gives himself. A prescribed amount of testosterone is injected into a muscle every 1 to 4 weeks. The “shot cycle” refers to the time between shots. The dose and frequency is adjusted until an appropriate response is achieved. Testosterone levels are often checked at the end of a cycle just before another shot is given.
- Testosterone pellet implants, such as Testopel, are implanted into the upper area of the hip during a minor office procedure. These pellets slowly release testosterone over several months. Most men can go 4 months between implants.
- Clomiphene, or Clomid, is a medication that is commonly used to treat both male and female infertility. It is an anti-estrogen that works to increase a man’s natural testosterone by increasing brain signals (LH) to the testicles. Unlike other forms of testosterone replacement, it does not cause infertility or testicular atrophy (shrinkage). While it is not FDA approved for use in men, it has been utilized to treat hypogonadism for many years and is considered very safe.
- HCG, human chorionic gonadotrophin, also works at the brain level similar to Clomid. It is FDA approved and is injected three times a week. It is generally reserved for patients that are not a candidate for or who have not responded to Clomid.
After initiation of replacement therapy, most men see their symptoms markedly improve within one to two weeks.
There are side effects of testosterone replacement to be aware of.
- Polycythemia, or erythrocystosis, is a condition where there are too many blood cells being produced. This is tested for by checking your blood counts initially and at follow-up visits. This could potentially lead to a heart attack or stroke. It is easily managed with blood donations.
- Prostate Cancer is fueled by testosterone and if you have prostate cancer, testosterone replacement can make it worse. However, there is no good evidence to suggest testosterone replacement actually causes prostate cancer. It is important to not only get prostate cancer screening prior to initiation of testosterone replacement, but also continue screening as recommended by your urologist.
- Cardiovascular disease and testosterone replacement have an unclear relation currently. While some studies suggest a small increase in cardiovascular complications others actually show a protective effect of testosterone replacement. Testosterone replacement can lead to an increase in energy and exercise which can lead to decreased weight, better diabetes and hypertension control, and an improved overall cardiac health.
- Infertility is likely to occur while on testosterone replacement. The natural hormonal axis that leads to the production of sperm is disrupted by the replacement testosterone. If you are interested in future fertility you should discuss other options, including clomiphene, with your Urologist.