Friday, February 23, 2024

by Aaron Medaris

If you’re a sports fan like me, you’ve probably seen the commercials that run on ESPN promoting products to help men with low testosterone, or what they refer to as “Low-T.”

Celebrities such as Joe Rogan, Jeff Bezos, Alan Ritchson, and Sylvester Stallone all tout the benefits of utilizing testosterone therapy or TT for short. Heck you’ve probably seen your friends on Instagram and heard from your neighbor down the street how they’ve gotten leaner, shed fat faster, gained more energy, and reclaimed their sex life all because of TT. Sounds like quite the miracle treatment for aging males. With a lot of this “medical” information coming from non-medical sources, how to you best help your patients understand the true benefits and risks associated with TT? 

Chances are, as a primary care physician you’ve received plenty of questions about TT; given that the majority of testosterone prescriptions are written by primary care doctors. To help you be better prepared for those questions, we’ll look at important aspects that patients and HCPs should understand when contemplating if this therapy, such as, what is testosterone, how should we best test for it, what are the benefits, risks, and important facts patients should know about TT before beginning treatment. 

Testosterone
Testosterone is a sex hormone that plays a crucial role in the development and maintenance of male reproductive tissues and characteristics. It is produced primarily in the testicles in males and in smaller amounts in the ovaries in females. Testosterone is responsible for the growth of male reproductive organs during puberty, the development of facial and body hair, deepening of the voice, and the increase in muscle mass. It also contributes to bone density, fat distribution, and overall well-being. While it is often associated with males, females also produce small amounts of testosterone, contributing to their hormonal balance and reproductive health. Here are some additional functions of testosterone in males: 

1. Testosterone is also crucial for libido and sexual function. Testosterone is associated with the male sex drive (libido) and is crucial for normal sexual function. It influences sexual arousal and the ability to achieve and maintain erections. 

2. Having healthy levels of testosterone can affect mood and energy levels. Low testosterone levels may contribute to fatigue, mood swings, and a decrease in overall energy. 

3. Testosterone influences fat distribution in the body. Lower levels of testosterone may lead to an increase in body fat, especially around the abdomen. 

4. While the relationship is complex, some studies suggest that testosterone may play a role in cognitive functions, including memory and spatial abilities.

Testosterone Changes with Age

Testosterone levels typically undergo changes with age, and these changes are a natural part of the aging process. The pattern of testosterone level changes can vary among individuals, but there are general trends. Here's an overview of how testosterone levels change with age in males: 

Puberty (Adolescence): Testosterone levels begin to rise during puberty, typically starting around the age of 13 to 15. This surge in testosterone is responsible for the development of secondary sexual characteristics, such as facial and body hair growth, deepening of the voice, and increased muscle mass. 

Young Adulthood: Testosterone levels peak in early adulthood, usually in the late teens to early twenties. During this period, males experience optimal levels of testosterone, contributing to reproductive health, muscle development, and overall well-being. 

Adulthood (30s and 40s): As males reach their late twenties and beyond, testosterone levels may gradually decline. This decline is a natural part of aging but is typically gradual and varies among individuals. Some men may experience a more noticeable decline in testosterone than others. 

Midlife (50s and 60s): Testosterone levels may continue to decline further in midlife. This phase is sometimes referred to as andropause, similar to the female menopause. However, the decline in testosterone is generally more gradual and less pronounced than the hormonal changes seen in menopause. 

Older Age (70s and beyond): Testosterone levels may continue to decrease with advancing age. However, the rate of decline varies, and not all older men experience significant decreases in testosterone. Some individuals maintain relatively stable testosterone levels throughout their lives. 

It's important to note that while testosterone levels tend to decline with age, not all age-related symptoms are solely attributed to lower testosterone. Other factors, such as lifestyle, diet, exercise, and overall health, can also influence well-being in aging individuals. 

Testing Hormone Levels – Free Vs. Bound

Testosterone in the blood circulates in two main forms:

1. Bound Testosterone: Testosterone can bind to proteins, primarily to a protein called sex hormone-binding globulin (SHBG) and, to a lesser extent, to albumin. Testosterone that is bound to these proteins is considered inactive because it is not readily available for use by cells.
2. Free Testosterone: Some testosterone circulates in the blood in an unbound or free form. This is the portion of testosterone that is not bound to proteins and is considered bioavailable. Free testosterone is available for use by cells and tissues in the body. 

In addition to bound and free testosterone, there is also a third category known as bioavailable testosterone. Bioavailable testosterone includes both free testosterone and testosterone that is loosely bound to albumin, and it represents the fraction of testosterone that is readily accessible for cellular use.

There are three types of blood tests measure these different forms of testosterone:

1. A total testosterone test measures free testosterone and bound testosterone that's attached to proteins. This is the most common type of test.
2. A free testosterone test measures only the "active" form of testosterone. This test is less common, but it may be useful for diagnosing certain medical conditions.
3. A bioavailable testosterone test measures free testosterone and testosterone that's loosely attached to a blood protein called albumin. This test isn't commonly done. But like a free testosterone test, it may help diagnose certain medical conditions. 

Total testosterone levels can vary among individuals, and what is considered a "normal" range can depend on the laboratory methods used for testing. Additionally, the reference ranges may differ slightly between different sources. 

Typically, total testosterone levels are measured in nanograms per deciliter (ng/dL). Here are general guidelines for normal total testosterone levels in males based on age (the values provided here are general guidelines and may not be applicable to every individual): 

Adolescence:

• Normal Range: 300-1,200 ng/dL 

Adults (20s to 40s):

• Normal Range: 300-1,000 ng/dL 

Adults (50s and older):

• Normal Range: 240-950 ng/dL 

Free testosterone levels, like total testosterone levels, can vary among individuals, and normal ranges may be influenced by factors such as the laboratory method used for testing. Additionally, free testosterone levels are usually reported as a percentage of total testosterone. 

Typically, free testosterone levels are expressed as a percentage of total testosterone. Here are general guidelines for normal free testosterone levels in males based on age (the values provided here are general guidelines and may not be applicable to every individual): 

Adolescence:

• Normal Range: 1.6% to 2.9% of total testosterone 

Adults (20s to 40s):

• Normal Range: 1.5% to 2.5% of total testosterone 

Adults (50s and older):

• Normal Range: 1.0% to 2.2% of total testosterone 

Testosterone Therapies

Testosterone therapy, also known as androgen replacement therapy, is a medical intervention aimed at supplementing or replacing testosterone in individuals with low testosterone levels. Here are some common testosterone replacement therapies: 

Testosterone Injections: Intramuscular injections are a common method of administering testosterone. Injections are usually given into the muscles, such as the gluteal muscles, and are typically administered every 1-2 weeks. 

Testosterone Gel or Patch: Topical formulations, such as gels or patches, are applied to the skin, allowing for absorption of testosterone into the bloodstream. Gels are typically applied to the shoulders, upper arms, or abdomen, while patches are applied to various areas of the body. 

Testosterone Pellets: Testosterone pellets are small, subcutaneous implants that are inserted under the skin, usually in the hip or buttock area. These pellets release a slow, steady amount of testosterone over several months. 

Testosterone Buccal System: This involves a small, medicated patch that is applied to the upper gum, releasing testosterone through the oral mucosa. 

Oral Testosterone: While less commonly prescribed, oral testosterone medications are available. However, they are associated with potential liver toxicity and are not as widely used as other forms of testosterone replacement. 

Testosterone Therapy Benefits

The potential benefits of testosterone therapy can vary among individuals and depend on factors such as the severity of the hormonal deficiency, overall health, and individual response to treatment. Here are some potential benefits associated with testosterone therapy: 

Improved Libido and Sexual Function: Testosterone plays a key role in sexual health, and individuals with low testosterone levels may experience improvements in libido and sexual function with testosterone therapy. 

Increased Muscle Mass and Strength: Testosterone is involved in the development and maintenance of muscle mass. Testosterone therapy may help individuals with low testosterone levels increase muscle mass and strength. 

Enhanced Mood and Energy Levels: Some individuals with low testosterone may experience fatigue, mood swings, or low energy levels. Testosterone therapy may contribute to improved mood and energy. 

Bone Density Maintenance: Testosterone is important for bone health, and its deficiency may contribute to decreased bone density. Testosterone therapy may help maintain or improve bone density in individuals with low testosterone. 

Improved Cognitive Function: While the relationship is complex, some studies suggest that testosterone may play a role in cognitive functions, including memory and spatial abilities. Testosterone therapy may have cognitive benefits in some individuals. 

Reduction in Fat Mass: Testosterone is associated with fat metabolism, and individuals with low testosterone may have an increased risk of accumulating body fat, especially around the abdomen. Testosterone therapy may contribute to a reduction in fat mass. 

Testosterone Therapy Risks

It's important to emphasize that testosterone therapy is not suitable for everyone, and its use should be carefully considered and monitored. Before starting any form of testosterone therapy, individuals should undergo a comprehensive evaluation, including a physical examination and blood tests to measure testosterone levels. 

Potential risks and side effects of testosterone therapy include:

• Polycythemia: An increase in red blood cell count.
• Acne or oily skin: Some individuals may experience skin-related side effects.
• Breast enlargement: Known as gynecomastia, this can occur in some cases.
• Sleep apnea: Testosterone therapy may worsen sleep apnea in susceptible individuals.
• Long-term safety and potential cardiovascular risks associated with testosterone therapy are still a subject of ongoing research, and healthcare providers carefully weigh the benefits and risks before recommending such treatment. It's crucial for individuals considering testosterone therapy to have open and informed discussions with their healthcare provider to make decisions based on their specific health needs and circumstances. 

Is Testosterone Therapy Right for your patient?

If a patient comes to you for the sole purpose of shredding fat and putting on muscle because of his buddy on Instagram has been posting daily about how his life has changed for the better because of TT. Be sure to have a real conversation about what testosterone therapy is truly for. It’s not for everyone and there are some real risks associated with it. But if a patient comes in expressing concern for fatigue, low libido, increased body fat, changes in hair growth, etc. it may be wise to discuss being tested for Low-T and potential therapy options.