Testosterone is the primary male hormone. There are enormous consequences of testosterone deficiency or excess on energy, libido, physical and mental condition and performance.
There is a gradual decline in the production of testosterone, about 1-2% per year, beginning in the 30s or 40s, and continuing into older age. Testosterone depletion results from the combined loss of pituitary and testicular function.
Suppressed testosterone may result from poor diet, nutrient depletion, illness, stress, or toxic effects of medication or environmental toxins. Alcohol and other recreational drugs, psychiatric drugs, heavy metal toxicity, exposure to insecticides and herbicides, can all be investigated as possible causes of testosterone deficiency.
The range of normal testosterone is wide, 300-1000 ng/dl. Levels under 300 ng/dl are considered deficient at any age. A decline in the individual’s testosterone level, even within the normal range, may initiate deficiency symptoms.
Testosterone levels should be measured in men with any of these symptoms. Testing is best performed in the morning, since testosterone will be higher at that time of day. Measurements of free or bioavailable testosterone may also be useful, since certain conditions, such as obesity, reduce the amount of testosterone available to the cells.
We measure hormone levels one month after starting therapy, to verify optimal dosage. Men with testosterone deficiency may respond rapidly and dramatically, often within days. Physical, mental and emotional symptoms that may have been present for years, can quickly improve
Testosterone Deficiency Symptoms
- loss of muscle mass
- reduced strength
- impaired athletic performance
- increased muscle pain at lower levels of activity
- increased risk of injury with physical labor or exercise due to weakened muscles, tendons, and ligaments
- reduced sense of well-being
- reduced energy
- depression, lack of drive
- increased abdominal fat
- osteoporosis
- loss of libido
- dysfunction
Testosterone Replacement Options
Pellets Placed Under the Skin
These are crystallized preparations containing 100-200 mg of testosterone, somewhat larger than a grain of rice. They are usually inserted under the skin of the buttock, after the skin has been cleansed, and local anesthesia produced with lidocaine. We insert a total of 4-7 pellets, depending on age, weight, and testosterone level. Pellets last usually 3-5 months, after which testosterone levels decline and the pellets need to be replaced. The benefit of pellets is that they will maintain an unchanging testosterone level, 24 hours a day, for months. All other preparations produce up and down levels.
Transdermal Creams or Gels
These are applied to the skin of the arms or thighs, once or twice a day. Though often effective, they will not attain the levels of testosterone produced by implanted pellets. Usual dose is 50-150 mg per day.
Sublingual Troches or Pellets:
These are applied to the skin of the arms or thighs, once or twice a day. Though often effective, they will not attain the levels of testosterone produced by implanted pellets. Usual dose is 50-150 mg per day.
Intramuscular Injections
These are employed once or twice a week, injected into the muscle of the buttock. Dosage is about 100 mg per injection. They can achieve high blood levels, similar to inserted pellets, but blood levels will decline over several days.
Oral Capsules
Not recommended. Bioidentical formulations have erratic absorption, and other formulations may potentially damage the liver
Precautions and Follow-Up
- Prior to starting testosterone, men should be tested for the level of prostate specific antigen (PSA), a marker for prostate cancer, and have a rectal exam to detect any prostate nodules or irregularity. Testosterone should not be given in the presence of prostate cancer, unless the cancer has been treated and is controlled or eliminated. Generally, it is good to wait 6-12 months after prostate cancer therapy to initiate testosterone therapy.
- After 3 months we retest PSA, and get a complete blood count. If the PSA rises above 1 point, testosterone should be withheld and the prostate re-examined. Testosterone may also increase blood count, and levels above the normal range may increase the risk of blood clots. If blood count is above normal, the dosage should be reduced.
- A portion of administered testosterone is converted within fat cells into estrogen. Estrogen levels may elevate, and breast enlargement or tenderness may occur. To prevent this, we may add chrysin, a plant preparation, or Arimidex, a drug, both of which block conversion of testosterone into estrogen.
- Sexual desire almost always increases with testosterone, but function is not always restored. Failure to achieve erection may then be due to impaired vascular relaxation within the penis, or to medication effects.