Beyond the commercials. Understanding low testosterone.
By Jill Case
If you watch TV, you have probably seen one of the commercials for gels that treat low “T.” The commercials, which list symptoms and side effects, may have left you curious about this condition. ATX Man talked to Dr. Kerem Ozer, an Austinarea endocrinologist, to help us learn more about this condition and the treatment available for it. Endocrinologists like Ozer see patients with low T symptoms or problems and provide evaluation, treatment and monitoring of the condition.
ATX MAN: Men are being exposed to so much advertising by the pharmaceutical companies about low testosterone. Due to this, have you seen an increase in the number of men asking about this problem?
Dr. Kerem Ozer: Absolutely. I think there has definitely been a shift. In the past, treatment for low testosterone was only done with injections. Since the gels have come on the market, and they are a much more practical way of taking testosterone supplements, I think awareness has increased. Currently, about 5 million men in the U.S. have low testosterone, and many more may not be aware that they have it.
AM: Maybe that is a good thing since those symp – toms are fairly broad—the fatigue, the weakness— and it could indicate other problems. Do you think this new awareness is a good thing?
KO: I definitely think so. A lot of the symptoms— fatigue, weakness, depression, erectile dysfunction— may be signs of other conditions, or they may be signs of low testosterone. In either case, I think it’s a good thing that people are much more aware of these symptoms and are coming in to have them checked out.
AM: In the past, these symptoms have been attributed to other causes such as depr ession or high blood pressure, but now, research has shown that these symptoms could be caused b y low testosterone levels. When a patient comes to y ou or another physician with these symptoms, do you do the blood test for low testosterone first, or do you rule out the other possible causes first?
KO: Yes, we do check for other potential causes of low energy like thyroid function or adrenal gland function, but even if someone has low T, he needs to undergo a detailed workup to figure out why they have low T. Low T may be due to a pituitary gland tumor, diabetes and other potentially treatable causes.
AM: I was surprised to learn that men can have hot flashes. Is that a symptom of low testosterone, or is it caused by a thyroid problem?
KO: Hot flashes, like fatigue and weakness, are pretty non-specific symptoms. In both men and women, hot flashes tend to happen due to changes in the thermo – stat in the brain (the hypothalamus). The hypothalamus does get influenced by sex hormones in both men and women, so it may be a sign of low testosterone. Having said that, changes in the adrenal gland or changes in the thyroid may also cause male hot flashes.
AM: If you do find that a patient has low testosterone levels, do you automatically test them for osteoporosis symptoms?
KO: Almost always. One of the main risk factors for osteoporosis in men is low testosterone, so it’s always a good idea to at least get a baseline bonedensity test to see where people are, especially in people who might have additional risk factors. These risk factors include vitamin D deficiency, being sedentary or people with changes in their calcium levels.
AM: Let’s talk about the types of treatment that are available to treat low T.
KO: There are three types of treatment. There are the gels, which are applied topically. There are also injections, which go into a muscle in the shoulder or the hip area. The injections are usually given every other week. The pellets are pretty new, and right now not many people offer them. They are inserted under the skin. It’s a minor procedure, and they usually stay under the skin for up to six months , delivering a slow release of testosterone that maintains healthy testosterone levels for the full six months.
AM: What are the pros and cons of treatments for low T?
KO: The short-term advantages include improvement in energy levels and improvement in muscle strength. Many people who experience depression as a result of low T levels will notice an improvement in mood as well. As far as sexual function goes, many men will see an improvement in their sex drive, as well as in their erections. Many men may also notice an improvement in muscle mass with treatment, especially if they begin to exercise. When men start taking the testosterone, their energy levels improve and they are more motivated to exercise, helping them to build muscle mass. In the long run, keeping testosterone levels in the normal range helps maintain and/or improve bone density as well.
AM: What are the cons to low-testosterone treatments?
KO: The main cons are the things we always keep a close eye on during testosterone treatment. The first one is testosterone’s effect on the prostate. Even the natural testosterone the body makes may cause, over time, prostate enlargement, so with testosterone treatment, there is potentially a small increase in the risk of prostate enlargement, especially in people who have had prostate cancer or who have a family history of prostate cancer. It’s important to keep a close eye on the prostate. When we start testosterone treatment, we always recommend that people have their prostate exam done once a year and have their PSA (prostate specific antigen) checked once a year. The other potential issue with testosterone that we monitor, especially in smokers and in people who have sleep apnea, is the red blood cell count. There can be an increase in the number of red blood cells that carry oxygen in the blood and that can cause a thickening of the blood and increase the risk of clot formation. We always keep an eye on this treatable condition. If the condition occurs, the patient donates a unit of blood to bring the cell count back to the normal range. Other less common side effects are increased acne, mood swings and very rarely, it can cause inflammation in the liver, but those are all things we keep an eye on with regular blood tests.
AM: Does the low T treatment help men with erectile dysfunction, or could there be other issues causing the ED even after the patient takes the low T treatment?
KO: In a lot of people, low T can be present with ED, and in a lot of people , once testosterone levels go back in to the normal, health y range, ED may go away. ED has several different causes and some people, even after we bring the testosterone levels back in to a normal range, may still need to use additional medications like Cialis or Viagra to help with the erection. Sometimes, even those don’t help, and then we look at additional factors like blood circulation or other conditions that can lead to ED.
AM: Are there any conditions that people have that prevent them from using low T medication?
KO: For most conditions, since this is a natural hormone that the body already makes, it doesn’t really interfere with other medications, so people with diabetes or heart problems can definitely use testosterone, again, being careful to monitor all the side effects. One main concern is prostate cancer. For most people who have or have had prostate cancer, treatment is not recommended. We look at the risk/ benefit ratio very carefully if we do think about treatment.
AM: Younger men can also have low T, right?
KO: Definitely. Both due to the fact that other conditions can lead to low testosterone and also just by virtue of the fact that lo w testosterone can happen at any age. People with low T symptoms should definitely consult a doctor, no matter what their age.
AM: What advice do you have about who should be tested and when?
KO: I think any man of any age who has symptoms like fatigue, weakness, depression, loss of libido or erectile dysfunction should be checked for low testosterone.
For more information, visit the Hormone Health Network: hormone.org/diseases-andconditions/ mens-health/hypogonadism.
Dr. Kerem Ozer is board certified in internal medicine and endocrinology, and is certified by the ISCD in osteoporosis testing. He practices at Texas Diabetes and Endocrinology (texasdiabetes.com). Ozer did his training in Houston with nationally recognized testosterone experts.