Testosterone plays a crucial role in men’s overall health, influencing everything from muscle mass, metabolic health, brain health, and bone density to mood and energy levels. However, testosterone levels naturally decline with age, and in some cases, this decline can lead to noticeable and problematic symptoms. Recognizing the signs of Testosterone Deficiency (often referred to as "low T") is essential for seeking timely medical intervention and improving quality of life.
Abbreviations and Terms:
TD = Testosterone Deficiency
T = Testosterone
TT = Total Testosterone = T in circulation that is bound to protein and is considered available for action once unbound
FT =Free Testosterone = T in circulation that is not bound to protein and is actively binding to receptors
DHEA = Dehydroepiandrosterone = a precursor hormone that may be converted to make T
Testosterone Deficiency Defined and Types of TD
First off, TD must include three criteria. These three are a low total testosterone level or free testosterone level on two or more occasions + clinical signs and symptoms of low testosterone + a medical history and physical consistent with low testosterone. Testosterone optimization therapy is different from therapy for TD. With testosterone optimization, a man may have a low normal or suboptimal level of T, but not qualify as TD.
TD can be divided into at least three or four different categories. Primary TD. This occurs in about 15% of cases and starts within the testicle, leading to low testosterone levels. For this discussion, I will not focus on primary TD caused by genetic abnormalities resulting in congenital TD.
Secondary TD occurs with abnormalities of the hypothalamic hormone GnRH and/or pituitary hormones, LH and FSH.
TD, classified as hypogonadism, occurs with low or absent sperm count with or without low T levels. A subset of hypogonadism is called late-onset hypogonadism or adult-onset hypogonadism (abbreviated LOH or AOH). Up to 89% of cases have no identifiable cause.
How Common is TD?
As time has gone on and more studies have been done to evaluate TD, even as a physician, I have been shocked to find out how common this condition is. Approximately 30% of men in their mid-40s have TD. This progresses to about 50% of men by the age range of 82–85 years.
When looking at obese teenagers ages 14 to 20 years, they have been found to have 50% less T than healthy BMI controls. In healthy men, starting at the age of 25, testosterone levels decreased by 0.3–1.4% per year. Total testosterone, free, testosterone, DHEA, and pregnenolone will all decline with age.
In healthy men with healthy BMI and muscle mass, TD is less likely to occur.
Signs and Symptoms of TD
Decreased Libido
A drop in sex drive is one of the most common signs of low T. While it’s normal for sexual desire to fluctuate over time, a significant or prolonged decrease may point to low T.
Erectile Dysfunction (ED)
ED is a multifactorial complex condition. The presence of ED alone does not suggest TD. Only about one in five men with ED will have TD.
Man Boobs
The medical term for male breast development is gynecomastia. There are three times in life that this occurs and may be considered normal. The first time is after birth, and with breast-feeding, a male infant may develop small breast buds secondary to maternal hormones. The second time is with puberty due to all of the homeowner changes. This is usually short-lived and resolves. In old age, when T levels are very low, mild gynecomastia may occur. Any other time this occurs and continues is abnormal. Consider gynecomastia, abnormal and hormonal fat deposits.
Loss of Muscle Mass, Increased Body Fat
When it comes to increased body fat and TD, this is the case of the chicken and the egg and which came first. Often, obesity is the inciting factor in younger men and teenagers. Unfortunately, having excess body fat results in more testosterone, being bound, and not free and hormonally active. On the other hand, TD will cause increased fat deposition and decreased muscle mass. When TD is present, it is more challenging to build muscle and lose weight. Further, keeping the muscles bulky and strong results in higher T levels. At least 52% of men with obesity will have TD.
Fatigue and Low Energy
There are many causes of fatigue and low energy, but these may be considered symptoms of low tea. Any time these symptoms are chronically present, a thorough evaluation for other conditions should occur.
Mood Changes and Brain Fog
Low T levels significantly affect mood. A man may experience increased tearfulness, depression, irritability, or emotional instability. Difficulty with focus and concentration is sometimes referred to as “brain fog.” Unfortunately, low T levels do affect the brain and, in older men, have been shown to be associated with an increased risk of dementia.
Hair Loss - Body & Scalp!
While hair loss is often attributed to genetics, low T can also play a role in the loss of both body and facial hair. Hormonal pathways may favor the conversion of T to estrogens and T removal from circulation by increasing 5-alpha reductase activity and converting it into DHT. DHT, not T, causes male pattern baldness.
Reduced Testicle Size, "Soft" Testicles
Low T will cause the testicles to shrink and feel softer than usual. This can be accompanied by reduced sperm production and infertility. Taking endogenous T, either prescription or as anabolic steroids (such as done by bodybuilders who are stacking), will result in the testicles shutting down or lowering T production. When this occurs, the testicles will shrink.
Other Conditions are associated with TD
TD is present in 74% of men who are chronic opioid users, 30 to 50% of men with type two diabetes mellitus, 30% of men with HIV, 42% of men with high blood pressure, and 40% of men with abnormal cholesterol levels.
Seeking Help
Low testosterone is a common issue, particularly as men age, but it doesn’t have to diminish your quality of life. Recognizing the signs and seeking appropriate treatment can help you feel like yourself again. Whether it’s through lifestyle changes, medical interventions, or a combination of both, there are ways to manage low T effectively and improve your overall health.
If you suspect you might have low testosterone, it’s essential to consult a healthcare professional. A simple blood test can confirm your testosterone levels, and your doctor can discuss potential treatments.
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