How Testosterone Replacement Therapy Has Evolved Over Time
Male menopause, low testosterone (low t) and testicular hypofunction all refer to the fact that male testosterone levels are low. The cause may be different, but the treatment is the same. Bioidentical testosterone replacement therapy (BHRT) and testosterone replacement therapy (TRT) also mean the same thing, at least in the United States because synthetic testosterone drugs can damage the liver. This makes them a poor choice for long term use. On your next trip down to Mexico you will see some of these behind the counter. The synthetic testosterone imitators are illegal in most first world countries. Examples are: methyltestosterone, fluoxymesterone, oxymetholone, oxandrolone, ethylestrenol, stanozolol, danazol, methandrostenolone, and norethandrolone.
Much has changed in 20 years since I graduated from naturopathic medical school. Back in the day, regular insurance-based doctors were very reluctant to prescribe testosterone. They would usually refer patients to an endocrinologist. To qualify for testosterone the patient would have to have very low levels, below 250 typically. Back then, after seeing the specialist, the patient would have to come in every two weeks, or perhaps once a month, and receive a shot at the doctor’s office. The problem with this is that for days following the injection T levels would be sky high and then by the time the patient was ready for their injection levels would be very low again creating an unpleasant hormonal roller coaster ride.
Times have changed a lot. Urologists are now well versed in testosterone replacement. Family doctors will sometimes prescribe it and anyone doing functional medicine or antiaging medicine with the DEA license is likely prescribing it. Helpful data has been published over the years on the effectiveness of testosterone replacement in the treatment of erectile dysfunction, depression, low libido, osteoporosis, cognitive impairment and metabolic syndrome. Testosterone replacement therapy does not need to be complicated; once a provider learns the nuts and bolts it is very easy to do.
Where Providers Can Fall Short
I have not been impressed with the skill of primary care doctors in treating low testosterone. Typically, an overpriced gel is prescribed and often the dose is not high enough to do anything. Additionally, I have found that PSA, estrogen, and red blood cell counts are not followed up on as frequently as they should be. I do not fault the primary care doctors as they have their hands full and do not have special training in testosterone replacement therapy. On the other side of the spectrum are ‘Low T’ clinics. What I found with these places is that there is a medical doctor who typically rubber stamps everything and I find the quality of care to be quite low. I hate to say this, but it has been my experience. I see many men who have presented with testosterone in the upper limit of normal and have still been prescribed shots, sometimes at a dose so high that they get dangerous side effects. In some cases, the lab follow up is good, and in other cases it falls short.
The Pros and Cons of Testosterone Replacement Therapy
The idea of testosterone replacement has a negative connotation due to its abuse in professional athletics. Body builders have a long history of self-treating with a variety of anabolic agents, some of which are quite dangerous. Treating low testosterone in a typical man is very different from its misuse in athletics. There can be too much advertising and too many false promises. Testosterone replacement is not nearly as amazing as it sounds on television. From my over 20 years of clinical experience the following are the pros and cons of testosterone replacement.
- Improvement in erectile function and libido
- Increased fat free body mass from 2-5 pounds
- Improved sleep
- Improved cholesterol and triglyceride numbers
- Increased energy
- Improved athletic performance especially at altitude due to increased red blood cell count and oxygen carrying capacity
- Improved exercise performance in endurance athletes who were training upwards of 12 or more hours a week and experience low testosterone as a result of endurance training
- Big improvements in mood, confidence and drive. In some cases, this is the biggest result and I’ve seen. Many men make important life-changing decisions after being treated for low testosterone.
Cons (including side effects which can be easily mitigated):
- Increased red blood cell count requiring blood donation 2-4 times per year
- Elevated estrogen, which requires taking a very small and inexpensive pill to treat it once per week
- Rare occurrence of acne
- Irritability and impatience, only seen when the dosage is too high
- Elevated blood pressure if red blood cell count is not monitored and patient does not donate blood
- Rare occurrence of increased hair loss due to a metabolite called dihydrotestosterone which can also be treated
- Testicular shrinkage or atrophy and decreased sperm count. This is reversible and does not cause sterility. Most older men do not mind if there is a minor decrease in testicle size. Upon stopping testosterone, testicles were returned to their baseline size and sperm count will normalize to original levels. More about this below.
What testosterone does not do:
You are not going to magically lose a lot of body fat nor will you look like a guy in a men’s magazine. If your level is low (below 300) you will notice improvements with strength training and exercise in general. The harder you work the better you will look. Promotional materials will talk about needing levels between 800 and 1,000. But more is definitely not better and getting levels up above one thousand would lead to great excess is estrogen and problems with red blood cell count, not to mention other problems. If you are a man with a testosterone level of 500 you will notice almost no benefit by going to 800. Increased libido is probably the only thing you would experience.
A holistic approach is best. If a man comes to the doctor with trouble sleeping, some erectile difficulties, weight gain, fatigue and depression a very detailed medical history should be performed. Other causes should be ruled out first.
How to Know if You Have Low Testosterone
There is something called the Androgen Deficiency in the Aging Male (ADAM) questionnaire that is sometimes used to screen for testosterone deficiency. The ADAM questionnaire asks the following questions:
- Do you have a decrease in libido (sex drive)?
- Do you have a lack of energy?
- Do you have a decrease in strength and/or endurance?
- Have you lost height?
- Have you noticed a decreased “enjoyment of life”?
- Are you sad and/or grumpy?
- Are your erections less strong?
- Have you noticed a recent deterioration in your ability to play sports?
- Are you falling asleep after dinner?
- Has there been a recent deterioration in your work performance?
Answering yes to more than three of these questions is supposed to alert doctors to test for testosterone deficiency. Doesn’t this sound similar to what men complain of after age 40? How about age 50 or 60? Plenty of men will complain of having every single one of these but could still have normal testosterone. How can this be?
The following factors can also result in any of the above listed symptoms:
- Poor diet
- A stressful lifestyle
- Lack of sleep
- Long irritating commutes
- Excessive stress
- An unfulfilling job, home life, or sense of community
- Separation from family of origin
- Lack of exercise
- Too much time inside and not enough time outside appreciating nature
- Too much sitting
- Excessive screen time
- Other medical conditions
Since the Covid-19 outbreak more men have been complaining of these types of symptoms that are not always linked to testosterone.
A common cause of low testosterone is a combination of being overweight and lack of sleep. Testosterone is made at night especially, early in the morning, and a good nights sleep is important for adequate levels. Moderate to intense exercise also increases testosterone. There is a feedback mechanism with obesity as well. Researchers are still not sure which comes first: low T or obesity, but it appears that being overweight shuts down testosterone production.
Finding the Best Type of Testosterone
What is the best type of testosterone to take? From a cost, benefit, and convenience standpoint I think that testosterone injection is the best method. We use the lab-combined (custom compounded) cypionate and enanthate forms for increased bioavailability. It is typically about ½ mL (100 mg) every seven days. In my practice we train the patient on how to administer their own shot. Injectable testosterone is very inexpensive. It costs between $60 and $100 for 20 weeks’ worth.
Another good method is the testosterone pellet. Small pellets are inserted underneath the skin in the buttocks area, and they typically last four months. A small incision is made during a sterile procedure and costs about $300-400. The benefit here is that consistent testosterone levels are obtained over a long-term period. We do this at our office.
I do not use creams, gels, or oral testosterone anymore in my practice. Results are highly variable and consistency is hard to achieve. Additionally, the testosterone can contaminate other family members very easily. Another downside is that it has to be applied every single day, and showering, swimming or sweating reduces its absorption. Men with extra body fat have a particularly hard time absorbing topical testosterone.
Alternatives to Testosterone
Human chorionic gonadotropin, also known as hCG, is an effective treatment for low testosterone. It is a hormone that is found naturally in the body. It turns on testicular testosterone production in men. It is also FDA approved as a fertility drug and for the treatment of undescended testicles in boys, and as a treatment for low T. hCG is very safe and effective with few side effects. It requires two injections per week with a small needle. It is however, a bit more expensive.
Necessary Lab Tests During Testosterone Replacement Therapy
Here are the lab tests that need to be performed at least every six months:
- Complete blood count to screen for elevated red blood cell count. This condition is called polycythemia and the problem with it is that excess red blood cells make the blood extra viscous which increases the workload on the heart. I always include a complete metabolic panel as well.
- There is some evidence that a substance called homocysteine may increase the risk for blood clots so this should be checked.
- A Prostate-specific antigen test also known as a PSA, screens for the very rare possibility of prostate cancer. Testosterone does not cause prostate cancer but if the patient had slow growing prostate cancer already, and then started testosterone, it could grow faster. This is why we require all our patients to get a PSA at least once per year.
- Estradiol, the medical term for estrogen, should be checked with every lab test, typically twice a year. Some men are very sensitive to even slight elevations in estrogen. Typical symptoms include nipple tenderness, difficulty losing weight, and increased emotional ups and downs, like crying at movies. High estrogen can also cause a condition called gynecomastia which is increased breast tissue in men.
- Dihydrotestosterone (DHT) should also be checked. High levels may cause some prostate enlargement and sometimes hair loss but nothing dramatic. DHT is a very potent type of testosterone. Lowering it too much with drugs like finasteride, also known as Propecia, can cause sexual side effects so one needs to be careful.
About me: I had the unique experience of working with a medical doctor who prescribed testosterone right after I got out of school. I then became proficient with testosterone replacement. I undertook additional training, including becoming board-certified through the American Academy of Antiaging Medicine. Even though I am well versed in testosterone replacement, in the state of Colorado a medical doctor must authorize the testosterone prescription. NatureMed Clinic has had a medical doctor on staff since 2006. All patients are required to meet with the medical doctor at least once a year.