Testosterone Deficiency

It is not uncommon to have one of my male patients ask me about “Low T” after noting a change in their
energy and vitality. While these symptoms are frequently reported in patients with low testosterone,
there is also typically a change in the patient’s sexual function; whether it be a decrease in their libido
(desire to engage in sexual activity) or having problems initiating or maintaining an erection.
Interestingly, there is also often a correlation between depression in men and having low testosterone
levels. Therefore, in men with treatment-resistant depression, I will often think about checking
testosterone levels.

There can be various causes to low testosterone and this is something I have to think about when first
discovering this in one of my patients. Certainly, there is a natural decline in testosterone as one gets
older, as testicular function decreases. Another common contributor to low T that I see in my practice is
obesity because the increased fat stores make chemicals and hormones that keep the brain from making
the chemicals that stimulate testicular function. In these patients, I do recommend weight loss as part
of their treatment plan. Medications can also contribute to low testosterone, such as patients who take
chronic opioids for conditions such as pain or medication-assisted therapy for opioid addiction. Another
consideration in some patients is whether they may have something in their brain, such as a tumor, that
is causing the brain’s hormone-control center to not function properly. These patients will often have
other hormonal disruptions and often complain of other symptoms such as recurrent headaches or
vision changes.

There are various ways to supplement testosterone if a patient with low testosterone desires to go that
route. The most common way we do this is by testosterone injection, primarily because this is the most
easily covered by insurers. Other treatments such as gels, patches and pellets are available, but can
often be cost-prohibitive.

When supplementing testosterone, we do want to keep an eye on several things. One is obviously the
testosterone levels themselves, not only to see if they are responding to treatment but also to see if
they are getting too high. Overly elevated testosterone levels can cause things like increased
aggression, irritability, acne, oily skin and even worsening sleep apnea. If a patient is not responding to
treatment in terms of adequate symptom improvement or maintaining appropriate testosterone levels I
will also check the estrogen in their blood. In some men, their aromatase enzymes will turn much of the
testosterone they are getting into estrogen. In these men, it is reasonable consider a medication that
blocks these enzymes to take in addition to their treatment and most find it very helpful. The other
thing I monitor is their blood counts, especially their red blood cell count. Testosterone can stimulate
the bone marrow to make more red blood cells and this can, at very high levels, increase the viscosity
(thickness) of the blood. In cases where this is happening, using less testosterone or having the patient
undergo therapeutic phlebotomy, or removal of some of their blood, can help with this. I also keep an
eye on the patient’s PSA (prostate-specific antigen) level before and during treatment. Testosterone in
and of itself can cause a rise in the PSA levels in some men. However, every once in a while, it can mean
that the patient has a prostate cancer that is being stimulated to grow by the testosterone treatment. If
there is suspicion for this, I typically hold testosterone treatment until this is investigated.

Testosterone therapy has improved the quality of life of many of my patients and is certainly an option
for those suffering from sexual dysfunction and low T when properly monitored.