Testosterone replacement for men – my views

Posted on Wednesday, April 23rd, 2014

UPDATE: a fresh look at the same topic from 6:2.18 courtesy of The Times

Testosterone deficiency, or low-T as it is popularly known in America, has long polarised medical opinion. Testosterone evangelists promote it as the panacea to middle-aged woes like poor sex drive, grumpiness and lack of energy, while at the other extreme sceptics regard supplementation as the unacceptable medicalisation of natural ageing.   But who is right?

Neither of them in my opinion, which is why I welcome new guidance from the British Society for Sexual Medicine which treads a path between these two extremes, confirming that testosterone deficiency is both real and common, but that not every man with low levels needs hormones to boost them.  

Testosterone deficiency can occur at any age and for a number of different reasons, but the bulk of the new guidance is aimed at the age-related decline seen in men over-40.  It is estimated that around 1in 10 men of this age has a low or borderline testosterone level, but that only 1 in 50 needs testosterone supplements. So how do you decide who does and who doesn’t?

Sexual problems , such as reduced libido and difficulties getting an erection, are the most common symptoms of low-T, but others include fatigue, poor sleep and depression.  All can be caused by myriad other problems common in middle age – not least stress – but where sexual dysfunction is prominent, a blood test to measure testosterone levels should always be part of the routine investigation. And because testosterone levels vary throughout the day (they are highest in the morning) it is important to take blood at the right time (before 11am according to the new guidelines).

If the result comes back as 12 nmol/l or higher then testosterone deficiency is unlikely to be the cause of  the man’s complaints. And if the reading is lower than 8 (and it should be repeated at least once to confirm this) then testosterone replacement therapy (TRT) is likely to be required. As ever in medicine it is the grey area in between – a reading between 8 and 12 – that confuses both doctor and patient.  

Men with higher readings (12 or more) generally only need reassurance. Those with levels under 8  should be referred to a specialist to decide if TRT is appropriate and what type (typically gel or patch) and dose.  While those men in-between (8-12) need further blood tests to check how much of their circulating testosterone is actually available (so-called free testosterone) before dismissing supplementation as some of them will still benefit.  

In many men with  borderline readings their lowish levels of testosterone are simply  a marker of their general health. If you are overweight, have type 2 diabetes, drink too much alcohol, or regularly take opiate based painkillers (such as codeine) then your testosterone level is likely to be on the low side.  Equally if you are slim, active and healthy it is likely to be normal whatever your age. So if free testosterone levels are OK in borderline cases I encourage weight loss and lifestyle change where applicable and re-test after 12 months.   

Compared with HRT in women, TRT is still in its infancy and there is fierce debate about the pros and cons.  Studies suggest that in the short term men can expect a boost to their sex drive, more energy, stronger bones and improved physical and mental stamina. But at what cost?  Potential worrying side effects range from acne and aggression to reduced fertility, and an increased risk of prostate cancer and heart disease. However the evidence is conflicting with some research suggesting that TRT protects against heart disease.

It may be a decade or more before we know for sure about the long term risks. In the meantime I would not even consider TRT unless I had a proven deficiency.  You can access the latest guidelines on diagnosis and treatment at http://www.bssm.org.uk/wp-content/uploads/2017/12/guidelines-on-adult-testosterone-deficiency-with-statements-for-uk-practice.pdf

 

Symptoms associated with low testosterone levels include:

 

 

  • Loss of sex drive, difficulty achieving or maintaining an erection (including loss of early morning erection) and reduced orgasmic sensation
  • Fatigue,poor sleep, hot flushes, night sweats, reduced physical strength and stamina and low mood
  • Weight gain, particularly around the midriff (although, this can cause low testosterone as well as result from it)
  • Decreased body hair and breast enlargement.

 

Edited to add: I have had lots of emails asking for specific advice on individual cases / interpret readings etc (see below) but really can’t give definitive answers on a blog. Medicine by email has its limitations, so please direct any clinical queries to your own GP / specialist. Thank you.

 

 

 

 

 

53 Responses to “Testosterone replacement for men – my views”

  1. Jim Barr says:

    Excellent article, I listen to your R4 program when I can. I have Haemochromatosis which caused diabetes and made having children harder; plus several other chronic disorders.

    I realise that the medication I am on has side effects, ( what medicines have NO side effects) but I reckon this topic is worthy of more exposure especially when so many men have problems that have a serious stigma attached, resulting in denial!

    BTW both my boys have made me proud, one Engineer and one Physics Phd, well worth the indignation!!

    Best wishes,

    Jim

    Jim Barr

    Best is the enemy of good enough

    Barrs law of recurcive futility:-

    If you’re smart enough to use one of these…..

    …..you can probably manage without one

  2. Cliff Brown says:

    i am suffering with 9 out of ten of the above, can you help me please

  3. peter dv jones says:

    I am 72 years old and expect a slowing down of vitality but as my GP has referred me to the local Erectile dysfunction NHS unit I think she accepts this is not the issue here. Problem is the unit is subject to heavy demand so the waiting time is horrendous. Having no wish to introduce unnecessary drugs or supplements but on the other hand I have no wish for this problem to continue getting worse. I have seen you on Tv which I would think is some corroboration you are likely to give sound advice. So can you Help???

    • Dr. Mark Porter says:

      Not much I can add from here Peter (and your message has only just come through). One to pursue with your own GP.
      Mark

  4. Paul Allen says:

    “But used inappropriately to artificially boost levels in men who have normal levels can have the opposite effect by increasing the risk of an early heart attack (as confirmed by a recent study from the States) and possibly a range of other problems like stroke and cancer of the prostate.”

    Hi, good info, do you have links to these studies relating to these negative effects?

    Many thanks.

  5. Anthony says:

    I suffer from erectile problems and difficulty maintaining an erection, I have recently had my levels checked at they came back at 15.9 n/mol although this is classed as a ‘normal range’ if you look at by age then my levels are the average of an 80 year old man when I am only 28. What are you thoughts with this?

    • Dr. Mark Porter says:

      Too high for TRT though. Did you have the test at 9am? If not check again. Are you overweight? If so try losing weight.

  6. Amanda says:

    My son is 19 and has low T, his last test was at 9am fasting.. 6.60 nmol/L

    It has now been low for 1 year, since first tested, pituitary gland tested came back clear.
    He also has low Ferritin 8 ng.ml …

    He lacks general drive in life, low energy, slight depression (not medicated) low concentration, fat displacement on back hip flanks, he seems to have little interest in girls.

    Please advise.

  7. Nathan says:

    Hi Mark

    I am 26 and have had 2 lots of bloods taken recently. first came back at 13.5 n/mol and second at 13.1 n/mol. both were taken at or as close to 9am. i though for 26 that is pretty low and would put me in the 5th percentile. i am not overweight and workout 3 days a week and rest adequately. could there be a possibility of low T? i know im a little above the reference range but surley it would be worth looking at. i have 2 children and i feel they are suffering because of my low energy and like you have said ‘enjoyment of life’.

    Many thanks

    • Dr. Mark Porter says:

      That is normal – albeit on the low side. Not low enough for TRT and there could be other causes.
      One to pursue with your own GP.
      Sorry for late reply – in my Spam folder

  8. Jack says:

    Hi. I have been to my doctor before with the though my T levels were low. I was told at the time they were within the ‘normal’ range. My symptoms have gotten worse. I have zero sex drive. Last time I had intercourse was 3 months ago and was forced by my wife to take a blue pill. All good for the mechanics but if you’re not interested in sex you’re just are not interested. I rarely get erections. If I’m lucky I master bate 1-2 per month. I can’t be bothered. I feel tired all the time and lack focus. My sleep is rubbish. I don’t feel I have energy to exercise any more and despite dieting and trying to keep below 1500 kCal per day I can’t seem to shift weight. It’s all very depressing. I recently had another blood test to tell me my levels were 11.8nmol/l. This is still within the normal range and my NHS GP still insists it’s within the normal range – albeit at the lower end. The range I was told was between 10-30. I asked what the demographics were for the levels agreed. He could not tell me so assume those levels considered normal come from samples collected from men of any age (20-100), of any BMI, if they smoke or drink or even have diabetes. From what I can see my level is that of the average expected from a man aged between 85-100. Indeed I feel that old. I am 47. What can I do?

    • Dr. Mark Porter says:

      Not much I can add (and sorry it so late but in Spam). I would not start TRT for people in the normal range and be inclined to look elsewhere to start with. But a private referral to and endocrinologist may settle it either way with further testing.

  9. GRAHAM says:

    I’m 32 and i have been experiencing low Libido and general fatigue for 12 months and made the decision to have Test checked, I scored 5.2 and then 6.5 after GP tested me 1 week apart. I have been referred to an Endocrinologist who has talked about the option of a Testosterone replacement Gel. My concerns are around the Fertility issues that are associated with taking TRT, what are your thoughts around the fertility side of things?

  10. Chris Dolby says:

    To an extent, it’s a lottery. My former GP put me on testogel with perfect results. When he left the practice, the next GP discontinued it, trying a range of other treatments that had no effect or bad side effects. GPs mostly do not read the guidelines from Royal Societies and endocrinologists on this, they just go by the rule of thumb which is based on tests alone rather than tests and symptoms. People live through years of hell consequently.

  11. Doug says:

    I have had unexplained fatigue recently and had full blood tests to try and find the cause. Most bloods were OK, except ldl at 3.3 (serum cholesterol was 5.8). On Liver results my GGT was high at 96 and my urate was 606 (I have gout!). HB1AC was in normal non diabetic range.
    I have also noticed variable libido over the last two years and requested testosterone test too (I had seminoma 15yrs ago). My serum test came in at 9.7 and my SHBG 21. My Doc says within normal range but it seems normal figure for a 100 yr old man. Could this be the cause of my fatigue and inconsistent libido do you think?

    • Dr. Mark Porter says:

      Sorry, just received this. Hard to comment. At 100 fatigue and poor libido are to be expected to some degree – albeit unwelcome.
      One to pursue with your own GP as there could be myriad other causes.

  12. Mark says:

    Hi. I was given low doses of amitriptyline to combat Tension headaches (caused by sleep issues). My sex drive died with 5 weeks and despite coming off the drug its never recovered. I did a private postal T test and got a level of 5.6 N/MOL. I followed up with my own GP and an NHS bloodtest showed a level of 8.6. My GP absolutely refuses to go down the testosterone treatment route due to increased cardio vascular risks.

    Any recommendations on who is best to see privately (which branch of medicine)? My general feeling from reading forums is the NHS is very reluctant to proscribe testosterone treatment in any circumstances

    • Dr. Mark Porter says:

      Sorry, just seen this. You should ask to be referred to an endocrinologist. I never start TRY with an endocrinologist opinion / support.

  13. Ben says:

    Hi, I am 19 years old who has a testosterone levels at 8.o nmol/L, tested multiple times, based on my LH and FSH the problem is due to my pituitary gland not working. I have been on trt for a year, and recently tried a restart but it failed to work. I was hoping you could tell me of some specialists In the UK I could contact.
    Thanks

  14. Simon says:

    Ive been suffering with ED for a few years now , but the strangest thing is I have no sex drive at all , It seemed to disappear once the ED started and has not come back.
    I had all my levels checked and I raised the HIGH SHGB score with my urologist who said it was completely normal.
    Could you please give me your thoughts on my results?

    Results Were as follows:
    Serum LX level = 7 iu/l ( range 1.0 – 9.0 )
    Serum follicle stimulating hormone level = 9.0 ui/l ( range 1.0 – 10.0 )
    Serum Testosterone Level = 20nmol ( range 9.4 – 37.0 )
    Serum Sex Hormone binding globulin level = 60 ( range 15.0 – 40.0 )

    Calculated Free Testosterone 268.9 pmol/l

  15. Andy says:

    I was blood tested with results of 4n/mol. I came to my conclusion after some real disturbing thoughts, slight depression, zero tolerance and a dead penis!
    I use a prescription gel, it work good.
    I am 45 very healthy and work out/run quite a bit, atleast 3 hours per week.

  16. Gary says:

    The problem is trying to get tested properly in the first place. GPs are reluctant to perform the test which leads people to tests and treatment by mail.
    At least in the US you can get whatever tests you want if your insurer covers it or are willing to pay.
    Is the best way to get one in the UK to find a private GP and pay the bill?
    Will any tests by mail be accurate?

    • Dr. Mark Porter says:

      An NHS GP will do the test if you have suggestive symptoms. But it needs to be done at 9am – or thereabouts. And repeated if low / borderline to confirm result.

  17. Turbotroll says:

    Hi,

    I’m a 38 year old male, displaying symptoms of ED. I’ve had my test results back from my GP, which revealed total testosterone of 19.5 nmol.

    As the test was taken at approx. 10.am, am I safe to assume my actual levels are higher than this and the ED problem lies elsewhere? In addition, do you have any info as what to the average hourly drop in testosterone is each hour from 9am (for men in my age group)?

    Thanks.

    • Dr. Mark Porter says:

      Hello,

      That is a perfectly normal reading – 10am is close enough to 9am not to be significantly different result wise.
      You can be pretty confident your issues are not testosterone related.
      One to pursue with your own GP please.

      Mark

  18. Ray says:

    I have just seen my GP to review my test results for low testosterone. On a scale of 8 to 30 she says that I am 29. I am 69 years old and I display all the symptoms of lowT. Has my GP misread the results do you think? Maybe my level is 2.9 not 29. It certainly feels like it. How can a GP not take in to consideration the age of the patient. If I was 19 I would expect that level, but not at 69. Can you offer any advice?

    Regards

    Ray

    • Dr. Mark Porter says:

      That is a reassuring result Ray – particularly considering your age. It is possible to misread results in theory, but abnormally low (or high) ones are generally asterisked or in red to avoid such mistakes.
      Low T type symptoms can be caused by lots of other issues and I would look elsewhere based on that reading.
      Regards
      Mark

  19. Anders says:

    Hello:)
    I have been tested several times total and free testosterone. Always Low.
    Total test: 4.5,8.3,7.3,8.7
    I dont understand how my numbers can change from 4.5 to 8.7?
    Always tested in morning.
    I have ED problems. Doctor and endo will only prescribe viagra and anti-d.
    28 years old. Not overweight and exercise 3 times a week.
    Shall I see second opinion or private clinic?
    Best regards

    • Dr. Mark Porter says:

      Testosterone levels do vary so it is not unusual to get results like yours – although they are low.
      Your first port of call should be to ask your GP why the endocrinologist felt testosterone supplementation would not be advisable / required. He/she is much better placed than me to advise.
      Or ask to see another endocrinologist privately for a second opinion.
      Good luck
      Mark

  20. Will says:

    Hi Mark. I’m surprised that nobody has mentioned free T which is more indicative than total T. This depends on how high the sex hormone binding globulin is. I have high total t (22) but high shbg (60, with the normal range being 17-55). This means my free t, (i.e. the available hormone not bound to shbg) is 320 which is in the bottom half of the normal range (200-650). Background: I’m 28, run for miles, don’t drink or smoke. Health freak, yet still have distressing symptoms of low T.

    • Dr. Mark Porter says:

      Hi,
      It can be an issue (mainly in older men) but your SHBG is only just above normal and your free T is well into the normal range. I would look elsewhere for the cause of your symptoms.
      Mark

  21. Mark says:

    Hi i went to see my GP regarding ED issues, he sent me for a testosterone blood check which came back with 3.8nmol/l, he has referred me to an endocrinologist and ordered a repeat blood test also. If the level remains this low would i be offered TRT? i’m 31 with congenital heart disease two mechanical heart valves & take warfarin. I felt awful for quite some time but put it down to my heart condition. My concern is that my cardiac history may make him nervous although i don’t have coronary artery disease, it’s a structural defect. Physically i’m relatively slim, exercise a few times a week, balanced diet etc

    Any information and opinion welcomed

  22. Sarah Bentall says:

    Hi, my husband has 7 of the above symptoms and recently went to a London clinic for TRT. His levels of testosterone were 8.3. He had a Nebido injection. My question is, does it have to cost this much money? It was £700 for the consultation and tests then another £800 for the 10 week injection, it will cost another £700-800 every 10 weeks. Can you get it on nhs or private insurance

  23. Mike Daly says:

    Hi Mark

    I have all symptoms as above and more, I’m 46, ED, penis numb and no sensitivity…..

    My T is 13.1nmol/l

  24. Alex says:

    Hi mark I’m 25 I took finasteride for my balding when I was 21 but stopped after a year due to sexual and mental side effects anxiety, erectile dysfunction and my muscles turned flabby with my pecs going drooping. These side effects have lessened but are still with me. My testosterone was 17 when I came off the drug now it is staying at 31. My docs say I’m on the upper end of normal and won’t even consinder sending me to an endo and says it’s in my head because the drug has left my system by now. Infeel it is possible that my body’s natural test was above the normal range and am not functioning because of that. My doctor tells me it’s in my head but I know that my muscles shouldn’t droop like that. Tried gym nothing works. I don’t know what I should do it’s ruining my life.

    Thanks

    • Dr. Mark Porter says:

      The finasteride effects have long gone by now Alex, and given your age and testosterone readings I would be looking for another cause. Is your sex drive normal?

  25. Ali says:

    Hi mark, this is an interesting discussion. The study you have referenced is quite small and low powered compared to some of the much larger studies that have been done recently which indicate no adverse cardiovascular effects from TRT. Have you read any of these? Quite happy to post some to stir debate and perhaps show the other side to TRT.

  26. Ali says:

    As promised I have brought some recent research with the hope of shedding some light on some of the perceived risks associated with TRT.
    This UK policy document is a good source as it brings some of the recent TRT research together and addresses some of the papers you have cited in your article http://onlinelibrary.wiley.com/doi/10.1111/ijcp.12901/full
    It suggests that the increase in CV risk often found is more likely to be related to poorly controlled oestrogen (often the case in TRT trials) than a direct effect from testosterone.
    There are a few interesting statements in this paper such as: ‘There is now strong evidence linking low T concentrations to aggressive, high-grade prostate cancer, higher rates of positive biopsy, biochemical recurrence and disease progression in men involved in active surveillance’

    • Dr. Mark Porter says:

      Thanks Ali, but with regard to your last comment, then long comes this even more recent research. No wonder men – and their doctors – are confused.
      http://www.cancerresearchuk.org/about-us/cancer-news/press-release/2017-11-04-low-testosterone-levels-linked-to-reduced-risk-of-prostate-cancer

      • Ali says:

        An interesting study, but it still does not support the view that increasing testosterone levels increases your risk of prostate cancer to more than that of a normal man.

        ‘They found that men in the group with the lowest levels of testosterone were significantly less likely to develop prostate cancer compared to all other men. Yet interestingly, when men in this group do get prostate cancer, they are 65% more likely to develop an aggressive form of the disease compared to all other men. For the men in the remaining nine groups, testosterone was not associated with prostate cancer risk.’

        So basically if you want to live life with horribly low testosterone then you might reduce your risk of prostate cancer but if you lead a normal life with good levels via TRT then you won’t increase your risk over the average man.

        ‘This is the first population study to support the hypothesis that testosterone receptors on prostate cells quickly become saturated. It appears that once that level has been reached, further increases in testosterone do not increase cancer growth.’

        In my opinion this research does not support your contention that testosterone replacement therapy increases the risk of prostate cancer over that of an average male. Thanks for the interesting study though!

  27. Ali says:

    Despite this I do agree with your general points regarding the importance of proper testing and screening for confounding factors. It seems unbelievable that testosterone is prescribed without any sort of blood testing in the US.
    I don’t entirely agree with your strict adherence to the ‘normal values’ that you’ve quoted. Do you not feel that there is some personal difference in when a man would experience low testosterone symptoms? Perhaps your 10.0 feels normal whereas for me I might experience terrible symptoms. This article ( https://www.optimale.co.uk/normal-male-testosterone-levels/ ) is an interesting look at what ‘normal values’ mean and whether perhaps these should be a little more flexible – a trial of testosterone may help someone on the edge of the values to decide whether TRT is for them (again as suggested by the UK policy document http://onlinelibrary.wiley.com/doi/10.1111/ijcp.12901/full). Thank you for your thoughts

  28. Michael says:

    Just had a Thriva result of 8.63 nmol/l, done as per the gold standard you’ve detailed. They say borderline at 10, suggesting low.

    36 year old, 92Kg, 5’11”, exercise avg. 5 hours of brisk walking a week, avg. 4 glasses of red a week, 2 beers, 2-4 shots spirits.

    My main problem is that I have a hell of a job ticking the boxes to the qualitative diagnostic questions that are generally the same for everything. Single, not dating, tired all the time, mild depression unmedicated, but I know I don’t lead a nice avg. life to put a scale against.

    I’m scientifically/skeptically minded and risk averse, however looking for a solution ‘on-line off-the-shelf’ vs. being treated like a neurotic for visiting my GP more than once a decade with something that’s not a battlefield injury, easy choice.

    Would it be reasonable to say looking for a lower dose product would be an ok approach and reviewing over long time periods, rather than upping doses quickly.

  29. Simon says:

    I got my results of Low T and to be honest im even more confused than i was before.
    I have zero libido and ED
    Scores were as follows: Total t in Blood = 20nmol
    SHBG = 60
    Calculated FREE T = 268 pmol
    doctor says ” Borderline results” and my ED is all my head !!! I havnt had a morning erection in 3 years so i think (as usual ) the doctors just want me out of the surgery
    I dont know where to turn now !

    • Dr. Mark Porter says:

      See guidelines in reply below. This are hot off the press and reflect latest thinking. Your levels are normal under these criteria and testosterone – or lack of it – unlikely to be the principal cause of your symptoms.

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