How low testosterone treatment can help – and harm – a man's sex drive and fertility
January 6, 2021
If you listen to sports radio, it seems as if every other ad is pushing a new low testosterone (low-T) treatment: More energy! Bigger muscles! Better sex! All with a simple pill, shot, or gel!
When something sounds too good to be true, it usually is.
Many men and a surprising number of providers don't realize that taking exogenous (synthetic) testosterone or over-the-counter supplements may have harmful side effects if not administered properly. Tinkering with your testosterone levels without direction from a qualified specialist can cause other health issues, such as testicular atrophy, infertility, and an increased risk of prostate cancer.
An estimated 1 in 50 men have low-T and experience symptoms such as less energy, decreased libido (sex drive), erectile dysfunction, lack of concentration, or trouble sleeping. Around age 30, a man's testosterone levels may slowly begin to decline. Approximately 35% of men in their 70s have low-T, according to the American Urological Association.
But we're beginning to see more men in their 20s with low-T at the UT Southwestern male urology clinic. Sometimes low-T is caused by medical conditions, such as genetic diseases or past chemotherapy or radiation therapy. More often, symptoms can be linked to sedentary lifestyle, poor diet, anxiety, or depression.
Safe, successful low-T treatments start with personalized conversations.
So, before you call that low-T clinic or click on an outlandish ad for testosterone-boosting supplements, find out what's at stake for your health. There are safer, more cost-effective options to restore youthful energy – and potentially reverse fertility loss from previous testosterone products.
What's a normal testosterone level?
Testosterone is a natural hormone produced primarily in the testicles, and it helps men maintain everything from bone density and body hair to sex drive and sperm production. However, you don't have to hit a certain number or level to be "a real man," despite what the constant flow of ads may tell you. What matters is who you are and where you are in your life.
On average, a testosterone level of 300–1,000 nanograms per deciliter (ng/dL) of blood is normal. Hypogonadism – reduced testicular function – generally occurs when the total testosterone is less than 300 ng/dL. However, a healthy level for you depends on your age, lifestyle, and bioavailable testosterone level – the unbound testosterone your body isn't using for daily functions.
Unlike many low-T clinics, we calculate bioavailable testosterone by measuring levels of two proteins, sex hormone binding globulin and albumin, that typically bind to testosterone. It's possible to have a normal total testosterone level and experience low-T symptoms if this balance is off.
Having a normal bioavailable testosterone level tells us your body is making plenty and you likely won't benefit from testosterone replacement therapy. If your bioavailable testosterone level is low, we can discuss options.
Risks of off-the-shelf testosterone therapy
Avoid supplements over the counter. None are regulated or approved by the U.S. Food and Drug Administration (FDA), which means you can't verify what they're made with or whether they're safe, even if they come with a celebrity endorsement. Some testosterone supplements have been shown to cause health conditions such as erectile dysfunction or kidney failure.
Low-T clinics tend to overtreat, making blanket recommendations around the patient's total testosterone and not their individual health needs.
Your best bet is to see a board-certified urologist with expertise in hypogonadism, or a fertility expert who is experienced in treating male patients. A personal approach can help you avoid a range of complications such as:
It is well known that exogenous testosterone can – and often will – cause infertility. Unfortunately, some doctors prescribe testosterone to treat infertility, and inadvertently make the problem worse.
Natural testosterone and sperm production is fueled by two hormones created in the pituitary gland of the brain: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). When a man takes synthetic testosterone, the brain detects the excess and slows or stops production of LH and FSH. That means the body quits producing intratesticular (natural) testosterone, and consequently, production of sperm due to the suppression of LH and FSH. This results in reduced fertility.
Little to no LH and FSH production, means no stimulation of the testicles. If the testicles aren't stimulated by these hormones, they may atrophy, or shrivel up. Testicular atrophy has been associated with long-term use of exogenous testosterone or over-the-counter steroids.
Development of male breasts
In some men, estrogen levels will increase as testosterone levels increase. Men naturally need some estrogen, one of the main sex hormones that women have, in the body for bone health and other body functions. But too much estrogen can cause conditions such as gynecomastia (male breast tissue). Excess estrogen can also cause sleep apnea, edema (swelling), and acne.
Increased risk of prostate cancer
I've had patients come to us from low-T clinics with testosterone levels as high as 3,000. That's unnecessary, and so much chemical modification increases the risk of enlarged prostate or increase the risk of prostate cancer. Even safe and moderate testosterone therapy bears a slightly increased risk.
Missed physical diagnoses
Low-T clinics typically don't screen for serious health conditions that can affect testosterone production. For example, patients may need bloodwork to measure prolactin, a hormone made by the pituitary gland that, in high levels, can be a sign of a pituitary tumor.
To follow a patient on testosterone replacement therapy, the provider should check your prostate-specific antigen (PSA), a natural protein that, in high levels, is associated with prostate cancer risk. You'll also need regular measurements of your hemoglobin (a blood protein) and hematocrit (red blood cells), which help carry oxygen through the body. An imbalance can indicate a serious medical issue, such as cancer, anemia, or kidney disease.
Untreated mental health issues
Often, we find that anxiety or depression – not hormonal imbalances – are the root cause of low-T-like symptoms. Suppressing your emotions can interfere with normal functions, such as focusing at work or maintaining an erection. If you truly have low-T, underlying stressors can make symptoms worse.
Everyone can benefit from an unbiased, listening ear now and then. I've referred many patients to see a therapist whose concerns resolve without testosterone therapy.
When testosterone therapy might help
Men who are no longer interested in conceiving may benefit from safe, monitored testosterone replacement therapy. Some patients with genetic issues that cause subfertility, such as Klinefelter's syndrome, may also benefit.
- Lose a few pounds: Approximately 30% of obese men have low-T. Since muscle burns more calories than fat, the more muscle you have, the less likely your body is to store excess calories as fat. However, some research suggests that low-T contributes to weight gain – it's a vicious cycle. Start by cutting belly fat, which is good for your heart health and general wellness.
- Eat a healthy diet: For full-body health and hormone balance, consider the Mediterranean diet, which focuses on lean proteins, healthy fats, and plant-based foods. Also enjoy foods that are high in vitamin D, which supports testosterone production, strong bones, and mood. Some of these include eggs, salmon, and mushrooms.
- Rethink online viewing habits: Pornography is readily available online and it can perpetuate skewed expectations for what masculinity and sexual virility should feel like. Your body was not designed to perform sexually for hours on end – what you're seeing on the screen is cinematography, not reality.
- Clomiphene citrate pills: The drug Clomid binds to estrogen receptors in the brain that cause a negative feedback on testosterone production. The result is an increase in LH and FSH production. My mentor gave a great analogy for this process. It's like putting an ice pack on a thermostat to trick it into cranking out more heat. Clomid encourages the brain to make more LH and FSH, and therefore make more natural testosterone.
- Injections: The hormone hCG can substitute for LH. Patients typically manage these short- or long-term therapies at home. We typically prefer not to prescribe testosterone injections for men in their late 20s and 30s, as these treatments are more likely to cause infertility. Exceptions would be individuals with a genetic problem that interferes with fertility or men who do not want to conceive.
- Aromatase inhibitor: The drug Anastrozole, more commonly used in breast cancer treatment, blocks the conversion of testosterone to estrogen. We typically prescribe this medication when there is a pertinent need because it can drive the estrogen level too low, resulting in fragile bones.
- Gels: This option offers varying degrees of absorption, and you must allow the gel to dry before getting dressed. Women should not make contact with the gel to avoid increasing their own testosterone level, which can cause side effects such as unwanted body hair.
- Nasal spray: A new drug, Natesto, allows for at-home dosing of testosterone with less risk of fertility loss. The testosterone absorbs through the lining of the nose, and application takes about 10 seconds per dose, three times a day.
- Patches: Similar to a nicotine patch, this option trickles testosterone into the system through the skin. Patches last about 24 hours and must be placed on an area of the body that is free of hair, oil, or irritation. It also can’t go over a bone or joint that will be disturbed by sitting, sleeping, or moving. You should not "reuse" a spot for at least seven days. Patches are not approved for age-related hypogonadism.
- Testosterone pellets: We can implant testosterone pellets into the fatty tissue above the buttock area. The pellets hold crystalized testosterone, which releases into the body over four to six months.
Recovering fertility after testosterone therapy
Regaining fertility is not guaranteed, but it is possible for some patients depending on their age and duration of testosterone use. The first step is to end any testosterone therapy and get baseline lab tests to know where your levels truly are. Often, we find that the patient's LH production has been suppressed. In those cases, the next task is to increase it. Most patients start with Clomid. If that isn't sufficient, we may consider hCG injections.
In rare cases when neither therapy works, we can consider increasing the FSH level as well with injections of the FSH substitute hMG. This drug is more expensive, and success is not guaranteed.
If you are concerned about low-T symptoms, or if you've tried therapies that didn't work, talk with your primary care doctor or urologist. Feeling better starts with a conversation about your needs, goals, and lifestyle. Personalized care from a board-certified urologist or male fertility expert is the healthiest way to get there.
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