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If you’re experiencing symptoms of low testosterone, it’s crucial to seek professional guidance to address these issues safely and effectively. In men, it’s diagnosed when levels fall below 300 nanograms per deciliter (ng/dL). Produced mainly in the testes in men and the ovaries in women, with a small amount made by the adrenal glands, its levels can significantly impact one’s quality of life. This increases the patient’s satisfaction with treatment and induces self-awareness for improvement in symptoms. However, symptoms such as changes in body composition, bone mineral density, lean body mass, muscle strength, etc., are difficult for the patient to appreciate immediately and require assessment of the treatment effects and feedback of the test results.
An overview of the assays available to aid in the diagnosis of testosterone deficiency is available in Table 4 (See button below). Given these inconsistences, prevalence of low testosterone has varied dramatically among studies, with statistics reporting %.5-8 A summary of findings from four large-scale contemporary prevalence studies can be found in Table 3 (See button below). Across the prevalence literature, the cut-off values used to define low testosterone vary widely, heterogeneity exists in the populations studied, the forms of testosterone used to measure testosterone (total and/or free) are not consistent, and the assays utilized to measure testosterone differ. The prevalence of testosterone deficiency in the American male population is difficult to quantify. Finally, testosterone pellets are also available in branded form, with no generic agents currently available.
Overall, seven studies reported no benefits on QoL in men using testosterone therapy compared to placebo,199, 205, 212, 225, 226, 230, 303, 318 while five studies demonstrated improvements.203, 317, 319, 328, 329 When only RCTs of men with baseline total testosterone values 326 It is unlikely that these changes represent clinically meaningful differences. There are conflicting results in the literature as to whether testosterone therapy has a significant impact on these symptoms. Men who seek medical care for possible testosterone therapy often present with non-specific symptoms, such as low energy and fatigue, which can be manifestations of other conditions, such as chronic stress, chronic fatigue, and depression. Studies reporting optimal testosterone levels yielded a mean 2.2 kg increase in lean body mass compared to a non-significant 0.8 kg increase when suboptimal levels of testosterone were achieved. As with other symptoms, the duration of testosterone therapy likely has a significant impact on overall bone density benefits. An increase in BMD is an important potential benefit of testosterone therapy for men who might be at risk for LTBF.
Voice alterations, similar to those observed in male puberty, have also been observed in male transgender after 3 to 6 months of treatment. A prospective study evaluating transgender men, with no history of psychiatric diseases or use of medication, who were submitted to different types of testosterone formulations in one year, demonstrated an increase in sexual desire, sexual fantasies and masturbation frequency in 70% of the individuals. This drug is approved and available for therapy in Brazil, but its prohibitive cost makes it impracticable as a regular treatment, especially in the public health system. Not every option is available for therapy in Brazil.9 Oral testosterone (17 methyltestosterone or fluoximetazona) is not recommended because of excessive liver toxicity. The testosterone treatment's main goal is to start the development of male physical characteristics.
Conversely, a recent study exposing patient testes to radiation (3 patients 17Gy and 4 patients 24Gy) demonstrated normal testosterone levels up to 3 years after radiation exposure.147 Men who have had exposure of their testes during radiation therapy, either through direct or scatter radiation, are possibly at risk for low testosterone and the Panel recommends total testosterone measurement in such patients. Recent studies have explored the association between varicocele and low testosterone levels, and while there is no definitive evidence that varicocele presence is a cause of low testosterone, accumulating data suggest that ligation surgery might increase serum testosterone levels. Adjusted logistical regression showed an inverse relationship between total testosterone and the presence of ED, with a probability of experiencing ED increasing as total testosterone levels decreased. Likewise, while some literature suggests that food ingestion might affect testosterone levels, the evidence is particularly weak, and the Panel does not recommend that clinicians insist on fasting prior to testing. Likewise, while some literature suggests that food ingestion might affect testosterone levels, the evidence is particularly weak, and the Panel does not recommend that clinicians insist on fasting prior to testing.Circadian Rhythm. Testosterone levels should be measured every 6-12 months while on testosterone therapy.
There does appear to be a trend towards lower total testosterone and a diagnosis of ED. There is a great deal of variability across studies with respect to the forms of testosterone measured (total versus free), the assays utilized to measure testosterone, the time of day when the sample is obtained, and the number of testosterone measurements taken. As an example, a total testosterone value of 250 ng/dL may be considered low based on the current guideline but be marked within the normal range by the laboratory. Well-established reference ranges constitute the essential basis for identifying whether the circulating levels of a particular analyte, testosterone in this case, are normal or low.
Improvements in sex drive were also assessed in another meta-analysis performed by Bolona et al.298 Using a variety of measures, the authors demonstrated improvement with a pooled effect of 1.31 (31% increase in sex drive) among men treated with testosterone, with greater improvements noted among men with lower baseline testosterone levels. A 2005 meta-analysis by Calof et al.190 pooled data from 19 RCTs to determine the number of all-cause prostate events in men who were on exogenous testosterone treatment compared to men who were on placebo. The Testim Registry in the United States followed PSA changes in men without prostate cancer who were on testosterone therapy.
To be scientifically accurate, the Panel chose the term testosterone deficiency. Clinicians may use aromatase inhibitors, human chorionic gonadotropin, selective estrogen receptor modulators, or a combination thereof in men with testosterone deficiency desiring to maintain fertility. The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility. Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low) for support of Strong, Moderate, or Conditional Recommendations.
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