Testosterone has been available as a medical therapy since the 1930s, yet testosterone use in men has seen dramatic growth in recent years, with men visiting their physician up 55 percent from 1.2 million in 2009 to 1.9 million in 2013 to discuss testosterone therapy, alongside a 10-fold increase in testosterone prescriptions in the U.S. This rise is in part due to an increased awareness of medical symptoms associated with lowered testosterone. But sky high use of testosterone therapy is also a consequence of aggressive direct-to-consumer advertising which promotes a "fountain of youth" myth regarding testosterone use, or otherwise may be "selling a disease."
Alongside historic high levels of testosterone use, controversy has swirled in recent years regarding safety of testosterone therapy primarily in regards to prostate cancer and heart disease. With contrasting extremes rampant that testosterone can kill as well as revive long life, many men find themselves confused and asking exactly how much testosterone makes a man?
The "Low T" Trainwreck
Testosterone deficiency medically is called hypogonadism. The testicles have two major functions: sperm and testosterone production. Hypogonadism represents a decrease in one or both of these actions. The common term "Low T" is a massive oversimplification of what can be a complicated array of endocrine dysfunctions that vary from direct disease of the testes, to dysfunctions of brain biochemistry which stimulate the testicles to work, and all of which can lead to testosterone deficiency.
Because testosterone affects many tissues, lack of testosterone can cause a variety of different symptoms. Reduced sexual desire, erectile dysfunction, fatigue, depressed mood, and reduced muscle mass are some of the most common symptoms of low testosterone. But because many of these symptoms of testosterone deficiency are nonspecific, the cause of them can in fact often be multifactorial in origin and extend beyond testosterone levels alone. Attention to insomnia, obesity, sedentary lifestyle, diet, thyroid and mood disorders, relationship quality, and high life stress among many other factors must be considered alongside evaluation of hormone production for men who feel poorly.
Loss of spontaneous non-sexual related erections, small size of the testicles, and breast tissue development or nipple discharge are distinct symptoms that an endocrine disease is a likely culprit for a man feeling unwell due to low testosterone. An accurate diagnosis of what is called primary vs. secondary hypogonadism with a medical specialist who understands detailed physical exam findings, symptom profiles, and lab and image testing procedures are important first steps in understanding whether testosterone therapy is appropriate for a man and what therapy might do for him. Testosterone therapy is of little use to an otherwise healthy guy, and therefore a man who doesn't need testosterone but takes it anyway is only subject to possible risk of treatment.
Research has shown that testosterone deficiency is associated with a number of significant health issues such as diabetes, obesity, metabolic syndrome, and bone fractures. Men who meet medical criteria for treatment should receive therapy. The burden of hypogonadism increases with age and in the presence of certain medical conditions. Men who are 80 years old have testosterone values that are one-half to one-third of those in men who are 20 years old. It is currently controversial in medical guidelines as to whether testosterone loss due to aging alone should be treated, however, most clinical experts agree: low is low, and men who meet symptom and appropriate lab criteria for testosterone deficiency deserve treatment at any age. Up to 50 percent of diabetic men have clinically low testosterone levels, and poor lifestyle and obesity are known to be directly related to decreased testosterone production for millions of men. In fact it is critical to understand that low testosterone associated with obesity and poor self care can be reversible with lifestyle changes such as weight loss, diet, and improved fitness. If low testosterone symptoms are occurring as a result of an underlying and correctable health condition, then it is important to treat that underlying condition rather than just try to normalize the testosterone levels with hormone therapy in isolation.
The Tortured Tale of Testosterone Harm
While testosterone therapy for men who need it may provide numerous health benefits such as improved energy, mood, muscle strength and sexual function, there is also a long list of possible consequences of taking testosterone. Testosterone therapy suppresses normal testicular function, and therefore it is necessary to understand shrinkage of the testicles will likely occur with long term use as well as cause infertility for a man of any age. Another common consequence of testosterone therapy includes changes to red blood cells, and any man undergoing testosterone therapy should be monitoring regularly by a medical provider to evaluate treatment response and manage consequences of therapy.
Medical science has long debated the effects of testosterone therapy on prostate cancer, and more recently whether use will cause a heart attack. The historical concern that testosterone therapy promotes prostate cancer appears now to be unfounded, but men should be screened for and discuss personal or family history of prostate disease with their clinician. Recently the Endocrine Society and the FDA have issued statements suggesting testosterone has potential concerns in regards to cardiovascular safety; yet the data that prompted this concern was highly controversial, deeply flawed, and attacked as "medical literature malpractice" by over 25 international medical societies. The vast majority of medical science has not shown there to be any conclusive link to heart attacks in over 51 studies. While this is an active area of controversy and research is ongoing, currently testosterone replacement is not considered to dramatically increase the risk of cardiovascular events by most experts. Regardless, every man undergoing testosterone therapy should be educated in the conflicting data, and engaged in individualized conversation and attention to cardiovascular risk parameters such as high cholesterol, blood pressure, and blood sugar levels.
The Testosterone Take Away
Men who are feeling poorly and have concerns about testosterone levels deserve clinically rigorous, evidence based, and holistic management. Men also need to be skeptical, independent thinkers, and educated in their exploration of whether hormone levels are influencing their health or not given the current environment of testosterone mass marketing coupled with permissive prescribing of testosterone for common, nonspecific, aging-related or poor self care symptoms which may be completely independent of testosterone deficiency.
Inappropriate testosterone prescriptions can cause unwanted consequences. Yet men appropriately diagnosed with testosterone deficiency should consider treatment after ample conversation about the benefits as well as risks individual to their specific health status. Testosterone therapy should always be discussed in context of healthy living and a multitude of other contributions that also interface with overall wellness, sexual function, prostate and cardiovascular disease, glycemic control, and bone health, all of which contribute to a man's vibrant quality of life.