Testosterone replacement for men – my views

Posted on Wednesday, April 23rd, 2014

Taken from my column in The Times 22.4.2013

HRT may have fallen from grace but, if a recent trip to the States is anything go by, the male equivalent, testosterone replacement therapy (TRT), is very much in the ascendancy. And we are starting to feel the impact here with the number of NHS prescriptions for the hormone rising fast, much to the concern of some specialists.

TRT isn’t new, but it is being marketed as never before thanks to a new range of testosterone products, particularly skin gels (even available in under-arm “roll-ons”). I have just returned from a conference in Miami and it was difficult to turn the TV on without seeing an advert featuring a grizzled middle-aged male model enjoying life with his glamorous wife after applying testosterone.

The buzz phrase in the States is “Low T” and you would be forgiven for thinking that it is the answer to any middle-aged man’s concerns. The adverts direct men to websites featuring a “screening” questionnaire (see below). And the questions are pretty banal – what middle-aged man doesn’t lack energy, feel grumpy or complain that they are not as good at sports as they used to be?

Most worrying of all is that a significant proportion of men taking TRT in the States haven’t even had their testosterone level checked. They are prescribed the hormone purely on the basis of their answers to the questionnaire, meaning many are taking the drug inappropriately and risking other health problems as a result.

What is particularly frustrating for specialists here in the UK is that the pendulum has rapidly swung from one extreme to the other. There is little doubt that testosterone deficiency has been under appreciated and under treated in the past but now, thanks to the marketing power of big pharma, we are likely to follow America and end up over-using it.

And that matters because if it prescribed properly, t men who need it, the effects can be transformational for everything from energy levels and wellbeing, to sexual performance. There is even evidence that it can reduce the likelihood of an early death in men with conditions like heart disease.

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.

Lots of middle-aged and older men do have lower than ideal levels of testosterone but for many it is simply a marker of their general health. If you are overweight, diabetic, a heavy drinker, if you take lots of opiate-based painkillers (such as codeine), or are just generally unwell then your testosterone level will fall. It does drop with age too but a fit middle-aged man won’t have a level much below what he would have had in his thirties. Replacing missing testosterone may help some of these men but it is no panacea for the afflictions of middle-age, or years of physical neglect.

TRT should only be used in men with proven deficiency confirmed by blood tests. Normal ranges vary from lab-to-lab but experts I have quizzed suggest that levels below 6 nmol/l confirm a problem. Men below 9 nmol/l probably have an issue, while those between 9 and 11 nmol/l might have one if they also have symptoms like low libido or difficulties with erections (see below). 12 or above and you need to look elsewhere to explain your symptoms.

And the test must be conducted properly. Testosterone levels vary throughout the day and the gold standard is to have the blood taken at 9am having fasted for at least eight hours before. And if the result comes back as low, it should be repeated to confirm there is a problem.

My next step would be to refer to a specialist because it is important that men are given the right type and dose of testosterone and are carefully monitored. The idea is to raise the level into the middle of the normal range and this requires skill and experience.

So if, like many Americans, you are taking the hormone on the basis of a screening questionnaire in the hope that it will turn the clock back, and you haven’t been formally tested then I would urge you to reconsider. And if you are going to the States, look out for the Low T ads and be grateful we don’t have direct consumer advertising for prescription-only medicines here in the UK. Yet.

 You can hear me debating the pros and cons of TRT with UK experts by visiting the Inside Health page of bbc.co.uk/radio4

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.

 

The androgen deficiency in the ageing male (ADAM) questionnaire is a popular screening tool in the States – albeit controversial here in the UK

 

1. Has your sex drive diminished?

2. Do you lack energy?

3. Have you lost strength or endurance?

4. Have you lost height?

5. Have you noticed a decreased “enjoyment of life”?

6. Are you sad or grumpy?

7. Are your erections less strong?

8. Have you noticed a recent deterioration in your ability to play sport?

9. Do you fall asleep after dinner?

10. Has there been a recent drop off in your performance at work?

 

If you answer yes to any of the first seven, or if you answer yes to more than three in total, you MAY have low testosterone.

 

UPDATE 3/2017- this is a report from Medscape of a new and worrying finding. Visit www.medscape.com for full report:

 

LOS ANGELES, CA — In a randomized trial of 138 older men with age-related low testosterone levels, those who received testosterone gel (AndroGel, AbbVie) for a year to attain youthful testosterone levels had a 20% greater buildup of noncalcified plaque in their coronary arteries than those who received a placebo gel[1].

These findings from the Cardiovascular Trial—one of the seven National Institutes of Health (NIH) Testosterone Trials (T Trials) examining different clinical outcomes in older men with age-related low testosterone levels who receive testosterone or placebo—were published in the February 21, 2017 issue of the Journal of the American Medical Association.

The men had a mean age of 71 and a high prevalence of cardiovascular risk factors, and half had severe atherosclerosis.

The findings “should at least strike some caution in people, to not be too laissez- faire” about testosterone therapy in similar men, Dr Matthew J Budoff (Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center) told heartwire from Medscape.

“Plaque progression is bad; there’s no mechanism by which this could be helpful,” he continued. When treating men with low testosterone, “I would be more cautious in patients who have already had a cardiovascular event or have significant atherosclerosis [and] tell these men that either we should forgo testosterone or use a much lower dose.”

The study dose aimed to give 70-year-old men the testosterone levels of 30-year-old men, which may not be warranted. “Maybe once you’re 70, you don’t have to be 40 again,” Budoff observed. “It didn’t work out so well for women either in the hormone-replacement trial.”

Perhaps “more modest doses of androgen or . . . forgoing it depending on their risk should be considered,” he added. “Certainly a larger trial needs to be done with heart attack and stroke, but until we have more data I just think this should raise some caution.”

An editorialist[2] goes even further, saying the findings are “unprecedented ” and “ominous.” Dr David J Handelsman (University of Sydney, Australia) writes that “the coronary luminal narrowing observed over 12 months in this study is an unprecedented drug effect and appears ominous in signifying accelerated atherosclerosis and is perhaps a harbinger of increased cardiac ischemic events.”

Effect of Testosterone on Coronary Plaque

The trial aimed to test the hypothesis that testosterone therapy would slow the progression of noncalcified coronary artery plaque volume in older men with age-related low testosterone.

Since this was a 1-year study and it takes longer to see changes in calcified plaque, the researchers examined “noncalcified plaque, which represents the more active plaque in the coronaries” and is associated with myocardial ischemia and subsequent cardiovascular adverse events, Budoff explained.

Secondary outcomes included total plaque volume and coronary artery calcium score.

The researchers analyzed data from 138 men (73 men in the testosterone group and 65 in the placebo group) at nine sites who had coronary artery plaque volume assessed by coronary computed tomographic angiography (CCTA) at baseline and 12 months.

The men were 65 or older, with average serum testosterone below 275 ng/mL, and subjective complaints and objective evidence of sexual dysfunction, physical dysfunction, and/or reduced vitality.

Most were obese (mean body-mass index [BMI] 30), hypertensive (66%), or former smokers (66%), and close to a third had type 2 diabetes (30%). The men had an average coronary artery calcium score of 250 Agatston units, which is “pretty high but not an outrageous number; you would expect a 70-year-old man to have some coronary calcium,” according to Budoff.

The men in the treatment group received an initial 5-g/day dose of testosterone gel, which was adjusted (based on regular testosterone determinations) to try to keep serum testosterone levels in the normal range for young men (280–873 ng/dL).

 

 

 

 

45 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.

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