Did you ever hear the term ‘grumpy old men?” Some say whether young or old, men may be feeling this way because of low testosterone. Low energy low sex drive, erectile dysfunction, loss of muscle mass and motivation, and loss of zest for life can be symptoms of low testosterone in both men and women. Low T (testosterone) is in a lot of commercials targeted at men. Is it the panacea to anti age and regain virility? The latest guidelines say no and there are caveats.
The Statistics on Low Testosterone
Testosterone levels begin to decline in men in their mid-30s and continues at an average rate of 1.6% per year.” Twenty percent of men older than 60 have low testosterone, 30% in those older than 70, and 50% in those older than 80 years. Low testosterone is defined as levels less than 270 even though the range goes up to 1,000. The older you get the more likely you will have low testosterone and the symptoms associated with it.
Symptoms of Low Testosterone
The most bothersome symptoms in those seeking treatment were
- Lack of energy
- Decreased strength and endurance
- Deterioration in work performance.
In patients who had not received treatment, the most bothersome symptoms were
- Erectile dysfunction
- Decreased sex drive
- Loss of energy or increased tiredness.
The big takeaways in this study of many studies used to create guidelines is that the recommendation is that:
- Testosterone replacement therapy should only be used in men for loss of libido and erectile dysfunction as per the guideline developed from studying many studies.
- Many of the men who sought treatment for factors other than sexual issues such as low energy, depression, loss of strength and endurance were given testosterone without measuring the levels to see if they were low or without evaluating the underlying cause of their symptoms.
- Evidence from 20 observational studies with a mean follow-up ranging from 0.73 to 10.3 years showed no increased risk for mortality, cardiovascular events, prostate cancer, or pulmonary embolism or deep venous thrombosis.
- Evidence showed little to no improvement in physical function, depressive symptoms, energy and vitality, or cognition.
- Evidence for quality of life was limited to results from the Aging Male Symptom scale, and the small increase was probably driven by improvements in sexual function. This scale only evaluates disturbances in potency, decreased morning erections, decreased libido and sexual activity, decreased beard growth, and the “impression of having passed the zenith of life.”
Issues to Consider
The big issues I see with these studies is that many men:
- Did not have their testosterone levels tested at baseline
- Weren’t evaluated for other underlying conditions
- Had infrequent or erratic follow up
- May have been given a trial of testosterone treatment because they hear the commercials and they have symptoms and ask their doctors for it.
- Preference was given to injectables because they are cheaper
- I have not seen any measures of downstream metabolites
There are clinics dedicated to treating low T; some are responsible, and others are medical mills that give prescriptions indiscriminately without adequate evaluation for other underlying causes or follow up. Some have a tendency to over treat and overdose. Many prescribers don’t go beyond measuring free and total testosterone levels. Testosterone can be converted into estrogen or dihydrotestosterone and each comes with its own set of risks, yet rarely are these measured. These are known as metabolites.
Functional Medicine Approach
As a responsible provider I test and don’t guess and look at the whole person as well as how each individual processes their hormones. What I frequently find is:
- Lifestyle is a major factor that influences low testosterone.
- Men who have large breasts and large bellies tend to turn any testosterone you give them into estrogen which makes them feel worse, hence the high dropout rate.
- Most clinicians don’t address stress or measure cortisol. High cortisol will lower testosterone and if you manage the cortisol and lower it, testosterone levels will rise on their own.
- Vitamin D, selenium and zinc deficiencies will tend to activate enzymes that lower testosterone by turning it into estrogen. Correcting these deficiencies can correct the underlying problem.
- Alcohol can also activate the enzyme aromatase that turns testosterone to estrogen.
- Compounded testosterone cream is better absorbed, better tolerated and less expensive than testosterone gel and it eliminates the peaks and valleys in mood and testosterone levels that occur with injections. It is more convenient as well.
Every individual is different. The guidelines elucidate that testosterone replacement therapy may be safe but did not show that it benefitted anything other than sexual dysfunction. Part of the reason may be there were other underlying factors that were not addressed, the study population or what the study was designed to look at. If you are considering testosterone replacement therapy, choose a physician who can take a more holistic approach and has a deep understanding of hormones as well as the lifestyle factors that can affect them. Other studies showed benefit and my blog Hormone Replacement Options for Men and Women has links to studies that show benefits as well as advantages for using topical testosterone. Follow up is essential to be sure the dose is in an optimal range and to determine what your body is converting it to.