Low levels of testosterone (hypogonadism) is commonly thought of as the main cause for many health problems men experience. From sexual issues such as low sex drive, erectile dysfunction and infertility, to psychological and cognitive issues such as mood problems, depression, anxiety and lack of concentration all the way to general health issues such as weight gain, muscle mass loss, low red blood cells, and low bone density.
The truth is that most men with low levels of testosterone are asymptomatic. And that for most of these problems, low testosterone is not the main cause.
With that said, low testosterone can be a real problem. In this article we will talk about possible signs and symptoms for low testosterone, how can you test for it, and the treatment options.
Low testosterone levels can be caused by a variety of causes:
Aging is the most common reason for low levels of testosterone in men. As men age, their levels of testosterone decrease. This is usually a normal part of aging. After the age of 30, testosterone levels decrease by up to 2% per year. This drop in testosterone is also referred to as “andropause” or “male menopause.”
It is estimated that about 19% of men over 70 have low testosterone levels, but when we look at men ages 30 to 79, only 5.6% have symptomatic low levels of testosterone.
Since low testosterone can be a sign of a medical issues, if you have low testosterone levels in your 20s, 30s or 40s it’s important that you speak with your doctor to find out the root cause.
Lifestyle factors can have a significant impact on your testosterone levels. The following lifestyle factors can lower testosterone levels:
- Lack of sleep
- Illegal drugs (and specifically anabolic steroids)
Stress, anxiety and depression can lead to low levels of testosterone in men.
There is a long list of medical conditions that can lead to a decrease in testosterone levels:
- Hypertension (high blood pressure)
- High cholesterol levels
- Medications side effects (such as antidepressants and narcotic pain medications)
- Type 2 diabetes
- Sleep apnea
- Liver diseases (such as cirrhosis)
- Endocrine issues
- Klinefelter syndrome
- Noonan syndrome
- Testicles injury
- Kidney dysfunction
- Chemotherapy or radiation
- Cancer and tumors
- Pituitary gland disease
- Autoimmune disease
- Metabolic syndrome
- Inflammation (such as sarcoidosis)
- Kallmann syndrome
- Head injury and brain surgery
- Hormonal disorders (specifically high levels of estrogen and prolactin)
Symptoms and signs
The list of signs and symptoms that raise suspicion for a low testosterone level are quite large. The problem is that most of these symptoms can be caused by other conditions unrelated to testosterone.
It is therefore smart to ask yourself if you experience multiple symptoms, and it is always best to speak with your doctor.
The signs and symptoms for low testosterone include:
- Low sex drive
- Erectile dysfunction
- Delayed Ejaculation
- Loss of body hair (over a long period of time)
- Loss of muscle mass
- Fatigue and low levels of energy
- Weight gain (especially in the belly)
- Poor memory and focus
- Enlarged breasts (gynecomastia)
- Weaker bones (osteoporosis)
- Mood changes and irritability
- Infertility or low sperm count
The diagnosis of low testosterone level includes a blood test for testosterone levels and an examination of the presence of at least one of the symptoms we mentioned above.
The blood test is usually best taken in the morning, when testosterone levels are the highest. Most doctors would like to have a second blood test at a different day since testosterone levels varies between days. To explore the presence of symptoms, you doctor will check your health history and do a physical exam.
Although not all doctors will perform further tests, we believe more testing is really important to the diagnosis. For example, getting FSH/LH to determine if it is a primary testicular or secondary testicular problem.
The underlying cause should be identified and addressed before deciding on a treatment plan.
When no medical underlying cause is found, the first line of treatment should be taking a look at lifestyle changes you can make to improve your health, which can in turn increase testosterone levels:
- Diet – Consider eating a balanced diet which includes a lot of plant based foods. Foods which includes vitamin D are thought to be good for normalizing testosterone levels. Being overweight has been shown to increase the risk of testosterone deficiency.
- Exercise – A 2012 study found that regular exercise increased testosterone levels in 14.5% in men who did not work out previously. This 2015 study found that physical activity increases testosterone even more than losing weight in obese men.
- Sleep – Sleep deprivation can lower testosterone levels. Low testosterone levels can also reduce sleep quality, which in turn can contribute to weight gain which further reduces testosterone. Therefore, it’s important to do whatever you can to get uninterrupted good night sleeps.
Testosterone replacement therapy
When lifestyle changes are not enough, some doctors will advise testosterone replacement therapy (TRT). Testosterone supplementation comes in a few different forms:
- Injections – testosterone injections are usually given every 2-4 weeks. They are the least expensive option but levels of testosterone can vary between each shot. These swings in testosterone levels can cause side effects such is instability in mood, and low energy levels.
- Gels, patches, or creams – These are applied daily directly to your skin. It’s important to make sure they do not transfer to other people, especially women or children. Patches are applied like band aids, so they are less likely to transfer.
- Pellets – These are placed by a doctor under your skin. They are usually replaced every few months.
It’s important to note that testosterone replacement therapy is controversial. In fact, a recent systematic review of 156 studies found that the evidence for the effectiveness of TRT is rather weak.
The researchers concluded the following:
- “Testosterone supplementation did not show consistent benefit for cardiovascular risk, sexual function, mood and behavior, or cognition. Studies that examined clinical cardiovascular endpoints have not favored testosterone therapy over placebo.
- Testosterone is ineffective in treating erectile dysfunction and controlled trials did not show a consistent effect on libido.
- Most studies on mood-related endpoints found no beneficial effect of testosterone treatment on personality, psychological well-being, or mood.
- The prescription of testosterone supplementation for low-T for cardiovascular health, sexual function, physical function, mood, or cognitive function is without support from randomized clinical trials.”
On the other hand, other randomized studies came to the opposite conclusions or suggest some benefit, especially when it comes to older men with hypogonadism (symptomatic low testosterone).
it is important to remember that testosterone is not approved to treat men with normal levels of testosterone.
Risks and side effects
Testosterone replacement therapy has many risks and side effects. In all cases testosterone supplementation should be taken with close monitoring of a doctor.
Testosterone “boosters” or “supplements” which are sold without a prescription online are not approved by the FDA and have not been shown to be effective. These could be dangerous and should be avoided!
Some of the less serious side effects of prescription testosterone supplements include a local response such as itching, redness, local pain, swelling, rash, etc. You should check the leaflet of the TRT supplement you’re taking.
Some of the more serious side effects include, hematoma, blood clots, risk of stroke, increased risk of erythrocytosis, problems with sperm production, enlarged prostate, high red blood cells count, testicular atrophy, and sleep apnea. There is mixed evidence for an increased risk for heart disease and prostate cancer.
The researches from the systemic review we talked about above concluded that “We identified no population of men with normal levels of testosterone for whom the benefits of testosterone use outweigh its risk.”
Testosterone supplementation is often touted online as a “fix all” cure for all men’s health problems and has been advertised as causing stronger erections to increased focus and memory. But the truth is that low testosterone symptomatic low testosterone is relatively uncommon, and in many cases may not be the leading cause of many of the problems it is claimed to cause.
Since testosterone replacement therapy is controversial and comes with a list of some serious risks and side effects, it’s important to weigh your options carefully, have thorough discussion with your doctor, and even consider getting a second opinion before deciding on a treatment option.
Medically reviewed by Oreoluwa Ogunyemi, MD.