Recently, I’ve been seeing a lot of men in my clinic who are concerned about low testosterone (hypogonadism, low-T).

This is interesting because only a few years ago I would rarely test for low testosterone, and any treatment was typically delivered by endocrinologists. With the availability of newer treatments, and with increased direct-to-consumer advertising, I am evaluating, diagnosing, and treating this disorder much more frequently.

Testing is simple.

A non-fasting blood draw, best taken in the morning. Results are usually back in a day or two.

Having low testosterone levels can make you feel lousy. Low levels of energy, depression, and a decreased libido are common complaints.

However, some men with low testosterone levels actually feel fine. I tell my patients that if they feel OK, treatment is not recommended. Low levels of testosterone won’t hurt you.

Obesity and hypogonadism often travel together, but which came first?

Interestingly, fat cells can convert testosterone into estrogen, so losing weight can bring up testosterone levels without any other treatment. Another cause of low testosterone is chronic opioid use. Opioids like oxycodone and hydrocodone are common culprits. Stopping the opioid will raise testosterone levels, but opioids and testosterone can be prescribed together.

Also, I always test for secondary causes of hypogonadism, including hemochromatosis, pituitary dysfuction, and prolactinoma.

Testosterone doesn’t come in a pill.

It has to be delivered by injection, gel, patch, buccal film, or subdermal pellet.

Shots are the cheapest, and are given every 1-2 weeks. Gels are applied daily and usually give the best results, as you don’t have as much fluctuation in the testosterone levels. The patches can be irritating to the skin, so I don’t prescribe those much. The buccal film is twice a day and expensive. The pellets are inserted under the skin every 3-6 months depending on testosterone levels. They seem like a good idea, but they haven’t really caught on.

The biggest problem with testosterone replacement is that we don’t know the long-term risks.

It seems likely that treatment will increase the risk of heart attack, stroke, blood clots, and prostate problems. But at this point we just don’t know. In the next few years hopefully we’ll start to have the results of long-term studies that define the risk. Treatment will suppress your intrinsic production of testosterone, and I’ve had a few patients with testicular shrinkage (“They’re like M&M’s, doc!”).

For now, you have to be comfortable with uncertainty to be on testosterone. The lawyers are definitely monitoring this for potential lawsuits, so I always make sure my patients have informed consent about the potential risks.

Monitoring while on treatment is required. I typically monitor hemoglobin/hematocrit, liver function, cholesterol, and prostate specific antigen. I initially recheck in three months, then usually every six months.

So in summary, testosterone deficiency is common and treatable.

Low levels do not mandate treatment in the absence of significant symptoms.

There are undefined risks to treatment with any form of testosterone (including compounded or “natural” products not prescribed by a doctor!)

In the right patient, and with appropriate monitoring, testosterone treatment can make a real life difference by improving energy levels, mood, and sexual function.