Andrology (Low T)
Recent television ads discussing “low T” have raised the awareness of the importance of testosterone in men of all ages.
The proper medical terminology of “low T” is hypogonadism.
Depending on the age of the individual, the lack of testosterone can have profound effects.
Because most patients who are concern about this condition are adults, they usually present with the following:
Hypogonadism “low T” Symptoms
- Fatigue
- Inability to concentrate
- Weight gain
- Loss of muscle mass
- Breast tissue enlargement
- Erectile dysfunction
- Ejaculatory dysfunction
- Infertility
- Loss of libido
- Hot flashes
- Osteoporosis
The causes of low T can be broken down to either primary or secondary hypogonadism
Primary hypogonadism is caused by the failure of the testicle to produce testosterone. In men, over 90 percent of the testosterone is made in the testicle while roughly 10 percent is created by the adrenal glands. Obvious causes of primary hypogonadism include surgical removal of a testicle for malignancy, mumps or other infection leading to damage of the testicle, scrotal trauma, use of exogenous steroid leading to testicular atrophy, and torsion of the testicle leading to atrophy or removal.
Secondary hypogonadism is caused by a lack of signals being sent by the pituitary gland to the testicle to stimulate the production of testosterone. Diseases that have led to this condition include:
- Aging
- Obesity
- Pituitary disorder such as a prolactinoma
- Abnormal hypothalamic development (Kallmann syndrome)
- Inflammatory diseases such as tuberculosis and sarcoidosis
- Medications such as certain opiate pain medication and steroids
- Elevated state of estrogen / estradiol
- HIV/AIDS
Workup for hypogonadism involves a detail history and physical examination focusing on the genitalia as well as recognizing the signs of delayed puberty.
In addition, blood tests evaluating the levels of free and total testosterone along with FSH / LH and estrogen and estradiol are usually drawn. Because there is a natural diurnal fluctuation of testosterone, the ideal time for these labs to be drawn is usually during the morning.
Other potential workup may include
- Prolactin levels
- Baseline semen analysis
- Cranial imaging
- Genetics – chromosome testing
- Biopsy of the testicle
Depending on the type of hypogonadism as well as the desire of the individual to remain fertile, the course of action differs.
For men who wish to remain fertile but yet would like to boost their testosterone level, they will need to rely on either Clomid or injections of human chorionic gonadotropin (HCG). Since Clomid is a pill, it is more popular amongst patients.
For men who have no desire to remain fertile, they are candidates for direct testosterone replacement therapy.
Options for this group include the following:
- Intramuscular injection of either short or long-term testosterone (Aveed)
- Quarterly implantation of testosterone pellets (Testopel)
- Daily topical application of testosterone (Androgel / Testim / Fortesa / Axiron)
- Daily application of testosterone patch (Testoderm)
- Slowly dissolving gum/cheek formulation (Striant)
Once an individual begins receiving testosterone therapy, they will need to be closely monitor by their prescribing physicians.
Routine laboratory studies will not only include testosterone levels but may also check levels of estrogen, estradiol, PSA, complete blood count, complete metabolic panel, and lipid profiles.
Prior to the initiation of any form of testosterone therapy, patients will need to be warn of the potential risks of stoke, coronary artery disease, prostate enlargement, and the inadvertent unveiling the presence of occult prostate cancer.
