Testosterone Deficiency Syndrome Andropause
If there is one hormone that makes a man a man, it has to be testosterone.
Testosterone is produced by the testis and is responsible for all male characteristics including beard growth, chest hair, muscles, deep voice, sperm production, aggression, energy, stamina and all the other good things that make us scary hunters.
So you can imagine when a man has insufficient testosterone, all sorts of things can go wrong.
What causes Low Testosterone?
Most of the time, it’s age. As we men get older, the production of testosterone starts to drop, usually from the age of 40. Being obese or suffering from chronic medical problems such as Diabetes, High Blood Pressure or High Cholesterol can cause the testosterone to fall faster and lower.
Damage to the testis from infections, trauma, radiation, heat or surgery can also lead to a decrease in testosterone production. A common cause is mumps. This is a common viral infection we get in childhood. Aside from causing a swollen face, it can also infect the testis. Another common problem is men who work in very hot environments. Hawkers are particularly at risk because they stand next to an open stove right at the level of their testis the whole day.
Undescended Testis and chromosomal abnormalities like Klinefelter’s syndrome affect testosterone production from a very young age.
Abuse of anabolic steroids usually for sports, can also shrink the testis and lead to a low testosterone level.
In the vast majority of cases, low testosterone is just a consequence of aging.
How do you know you have Low Testosterone?
Low testosterone affects you both internally and externally. Visual signs can be things like:
- Feeling low energy
- Putting on weight around the tummy
- Losing muscle mass
- Slowing down of beard growth
- Erectile dysfunction
- Low semen volume
- Unable to concentrate
- Unable to sleep well
- Short temper.
Having a Low testosterone can also cause your bones to become weak (Osteoporosis), increases your risk of high grade prostate cancer and increase your risk of chronic diseases such as Diabetes and High Blood Pressure.
A semi-quantitative way of knowing if your testosterone is low or not is to take the Aging Male Symptoms (AMS) Questionaire. The higher your total score is, the more likely your testosterone is low.
What tests do you need to do?
The standard test that has to be done is a blood test that measures the amount of Total Testosterone in the body.
Sometimes, we will also measure the Albumin and Sex-Hormone Binding Globulin (SHBG) levels also. This is because sometimes the amount of Total Testosterone is normal but most of it is stuck onto these proteins and therefore not available to the body for use. Using the Albumin and SHBG measurements, we can calculate the amount of free testosterone in the body. This gives a better measure of how much testosterone is actually active in the body.
We might also do a Full Blood Count (FBC) and Prostate Specific Antigen (PSA) test. This is because we need to monitor the amount of red blood cells in the your blood and the health of your prostate should you have to start on testosterone Replacement Treatment.
Of course, if we suspect your symptoms may be due to something else and not Low testosterone, we will test for those too.
What treatments are available?
There are several ways to put testosterone back into the body.
Testosterone pills are painless and convenient. The only draw back is that they have to be taken with an oily meal for the testosterone to be absorbed well by the body. This is because testosterone is only soluble in oil.
Gels are also painless and convenient. The only drawback is that you cannot swim, bathe, sweat excessively or do anything that might wash the gel off for at least 4 hours after applying the gel. You must also wash your hands thoroughly after application as you do not want to accidentally transfer the gel to someone who does not need testosterone. The usual joke I tell my patients is ‘you better wash your hands well if not your wife will grow a moustache!’
Probably the most convenient in the sense that after the injection you have nothing to do until the next injection. As with all injection, they are not painless. That said, they are not more painful than your average injection. There are different preparations. Some have to be given every 3 weeks, some every 3 months.
What are the side effects of Testosterone Replacement Treatment?
Testosterone replacement treatment is safe if given in appropriate doses. Those horrible side effects that you read about suffered by athletes and body-builders are probably due to over-dosing. Given in appropriate doses most people do not have any side effects. Relatively more common side effects are:
Hey, it’s called an anti-aging treatment isn’t it? So when you are young again you get the good with the bad! That is another joke I tell my patients.
In truth, testosterone stimulates the oil glands in the body. This could lead to more oil production and if the Acne bacteria is present on the skin, the patient could develop pimples.
2. Hair Loss
Testosterone is converted to DHEA in the body. This hormone can lead to male pattern balding. There are medicines we can give to prevent this side effect should it occur.
3. Changes in PSA levels
The PSA is a protein found in the blood. It can be raised when the prostate is inflammed or if there is prostate cancer. When a person starts on Testosterone Replacement Treatment, the PSA may go up slightly initially before settling down again. This does not mean the patient is developing Prostate Cancer. See the section on Testosterone and Prostate Cancer below.
4. Increase in estrogen levels
There is an enzyme in the body called Aromatase that changes testosterone’ to estrogen. Overweight people tend to have more of this enzyme.
The problem is when we give these patients testosterone, the body changes it to estrogen. Since estrogen is a female hormone, it can cause all the symptoms of having Low testosterone. It can also lead to the development of gynaecomastia aka ‘male boobs’.
For patients who feel great after starting on Testosterone Replacement Treatment then quickly start feeling lousy again, this is the most likely reason. To overcome this issue,we can get the patient to lose weight, adjust the Testosterone Replacement dose or give a medicine to block the body from converting testosterone to estrogen.
5. Thickening of the blood
Testosterone causes the body to produce more red blood cells. This improves oxygen delivery of the blood and increases stamina. This is one of the reasons athletes use testosterone. However, if the body produces too much red blood cells, the blood can thicken too much and cause problems.
I personally have not come across this problem in any of my patients. I think this is a problem only when a person abuses and over-doses on testosterone.
Testosterone and Prostate Cancer
There is still a widely held belief that testosterone leads to Prostate Cancer. This is not true.
For patients who already have Prostate Cancer, testosterone can make it worse. That said, I have patients who started Testosterone Replacement Treatment after they had surgery for Prostate Cancer. I co-manage them with their surgeons and they are doing very well.
For patients who do not have Prostate Cancer, Testosterone does not cause them to develop prostate cancer.
In fact, it has been shown in scientific studies that having a low level of testosterone actually increases a person’s chance of developing High Grade Prostate Cancer.
What should you do next?
If you feel you might be suffering from Low Testosterone, do the AMS Questionaire.
If your score is:
- > 50 – it is likely your testosterone level is low
- 37 – 49 – it is possible that your testosterone level is low
- 27 – 36 – it is unlikely that your testosterone level is low
- 17-26 – you do not have symptoms of low testosterone
Need more advice?
To find out more about Penile Rash or other Men’s Health issues , please visit your doctor or visit Men’s Health Clinic.
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Read our earlier blog entry on Andropause.
- Penile Discharge (Should I be Worried?)
- Frenulum Breve and Penile Frenulectomy
- HIV Symptoms
- STDs General Info
- Premature Ejaculation
- Erectile Dysfunction
About Dr. Tan
Dr. Tan graduated from the National University of Singapore in 2001. His residency was in the two largest public hospitals in Singapore; Tan Tock Seng Hospital and Singapore General Hospital.