Why is testosterone so important?
It may be the most misunderstood of all of the hormones in the body.
Thanks to anabolic steroids and the misuse of them, many people are afraid of testosterone and have received lots of false information about it.
In fact, it is an essential hormone that both men AND women need to live happy, healthy, energetic lives.
If the levels of testosterone are not optimal in your body, it will be almost impossible to have the quality of life that you should ideally have.
If you are having fatigue, loss of muscle strength, loss of libido, night sweats, headaches, cold intolerance, and if you are gaining belly fat, you may have a testosterone problem.
Let's dive into this hormone further to learn more about it and address much of the misinformation that many people may have. I will also discuss symptoms, testing and treatment.
What Is Testosterone?
Testosterone is a hormone that is produced in the testes and to a lesser degree in the adrenal glands in men. It is produced in the ovaries and adrenal glands in women.
Testosterone is the hormone that grows tissue in the body.
It is responsible for muscle growth, bone growth, hair growth, sexual function, sexual drive (libido) and is essential for overall health and feelings of well-being.
Testosterone Facts
- Men aged 30-70 will lose 1-3% of their total testosterone every year.
- Women will lose half of their testosterone production between ages 20 and 40.
Consequences of Low Testosterone
Let's dive into these more.
Heart Disease -
I believe that optimizing hormones is key for prevention of disease, including heart disease
Several studies have shown that testosterone not only doesn't cause heart disease, it is actually protective. Here is another study.
A study from the American Heart Association's journal Circulation showed that as the testosterone level drops in men, their risk of heart disease increases.
The authors even suggested that the testosterone level could potentially be used as a marker for predicting which patients were at high risk of developing heart disease.
By the way, doctors today are taught that statin medications (Lipitor, Zocor, etc) are essential to reduce the risk of heart disease.
In fact, if you follow some of the guidelines, the majority of adults should be on a statin.
However, whether statins actually reduce the incidence of heart disease is controversial.
I personally think it is more important to get the body into balance, including hormones. Most inflammation and disease will resolve without the need for medications.
Alzheimer's Disease -
Studies have shown that low testosterone has been associated with worsening cognitive function in older men.
On the flip side, it also appears that testosterone therapy improves mental function in men.
In case you're wondering, it also seems to help in women.
Diabetes -
A study published in 2013 found that low testosterone levels may help predict if a man will develop insulin resistance or type 2 diabetes in the future.
It is unknown whether low testosterone increases the risk of diabetes, or if both conditions are due to the majority of those patients being overweight.
Regardless, there is a definite connection between low testosterone and type 2 diabetes.
Prostate Cancer -
Doctors have been taught that testosterone can cause or worsen prostate cancer.
This simply is not true.
This belief was based on a flawed study from 1941.
Multiple studies have since shown no increased risk - Here, here, here, and here are some examples.
In one study, healthy males were given super high doses of testosterone, but they had no increase in PSA or the size of their prostate glands.
In fact, having low levels of testosterone was shown to be a risk factor for developing prostate cancer!
Osteoporosis -
1 in 7 of postmenopausal women have osteoporosis.
Half of all women over 50 can expect to suffer an osteoporosis-related fracture during their lifetime.
After a hip or vertebral fracture, death either caused directly from the fracture or due to a secondary problem is as high as 25-35%!
That is why we should do all we can to reduce this risk.
Testosterone has been shown to increase bone density.
By the way, calcium does not increase bone density significantly, but vitamin D reduced the risk of fractures by 16%.
Breast Cancer -
Testosterone also seems to protect against breast cancer.
It is believed that testosterone down-regulates the estrogen receptors in the breast which inhibits breast cancer growth.
Conditions such as PCOS where the testosterone levels are elevated are not associated with higher breast cancer rates. In fact, they may actually have lower rates.
By the way, micronized progesterone does not increase breast cancer and may in fact be protective.
If you are on synthetic progesterone (medroxyprogesterone, norethindrone, etc), you should talk to your doctor about switching to micronized progesterone (Prometrium or bioidentical).
There is also evidence that iodine supplementation reduces breast cancer risk.
Symptoms of Low Testosterone In Men
Symptoms of Low Testosterone in Women
If you have 5 or more of the above symptoms, you have a high likelihood of having a low testosterone level and it's time to go get tested.
Many of the symptoms of testosterone deficiency mirror those caused by other hormone issues, especially hypothyroidism and adrenal fatigue.
Are you tired because you have low thyroid, low testosterone, or adrenal fatigue?
What about your insomnia, or weight gain, or mood swings? Which one is causing it?
The answer is possibly all of them!
That is why you need a thorough history and comprehensive lab tests performed before your individual story becomes clear.
Bonus information for women: If you have hot flashes during the day - 40 seconds of heat that begins in your chest then moves to your face - you most likely have low estrogen levels.
If you have night sweats - you wake up drenched in sweat to the point that you sometimes even have to change clothes - you are most likely low in testosterone.
Diagnosing Testosterone Deficiency
I believe it is essential to diagnose and treat adrenal and thyroid issues before addressing the sex hormones such as testosterone.
They should at the very least be addressed at the same time.
If your testosterone is low but you are also dealing with adrenal and thyroid issues, you simply won't feel better until your adrenal and thyroid issues are corrected, even if the testosterone becomes optimized.
So, how do you know if you are low in testosterone?
Labs for Low Testosterone
Men -
- CBC
- CMP
- PSA
- Total Testosterone
- Free Testosterone
- Estradiol
- Lipid Panel
- 25-Hydroxyvitamin D
- Complete Thyroid Panel - TSH, free T4, free T3, reverse T3, TPO ab, Thyroglobulin ab
- CBC
- CMP
- Lipid Panel
- Total Testosterone
- Estradiol
- FSH
- 25-Hydroxyvitamin D
- Complete Thyroid Panel - TSH, free T4, free T3, reverse T3, TPO ab, Thyroglobulin ab
At this point, I have found insufficient evidence that salivary testosterone measurements are a reliable form of testosterone testing. I therefore recommend serum testing only.
It is important to point out that there is a difference between a "normal" reference range on a lab result and an "optimal" testosterone level.
On most labs, the normal reference range for testosterone in men is about 300 to 1200. That is a HUGE range.
Most insurance plans require 2 different total testosterone levels below 300 before they will pay for testosterone replacement therapy, whether the patient is symptomatic or not.
But people that are having symptoms may benefit even if their testosterone level is as high as in the low 600s.
The optimal range in men should be in the upper 1/3 of that range (I prefer 900-1100).
In women, most labs list a normal reference range of about 15-70 ng/dl.
However, excluding conditions such as PCOS, the optimal range for testosterone in women should be 150-250 ng/dl.
Who Qualifies for Testosterone Therapy?
Men -
A man qualifies and should be considered for testosterone therapy if:
- Serum total testosterone is <600
- He has several of the symptoms listed above
- His PSA is <2.5 (if >2.5, he should have a urological evaluation before being considered for therapy)
- Any vitamin D, adrenal, or thyroid issues have been addressed
Women
A woman is a candidate for testosterone therapy if:
- She has several of the symptoms listed above
- Her total serum testosterone is <100
- She has had a mammogram in the past year
- Any vitamin D, thyroid, or adrenal issues have been addressed
Treatment of Low Testosterone
Studies have shown that testosterone therapy improves many things, including libido, quality of erections, increased lean mass, increased bone density, improved lipid parameters, reduced fat mass, and improved blood sugar control. Here are 2 examples - here and here.
With that in mind, let's look at treatment options.
Men -
There a 3 types of testosterone therapy available for men - topical, injections, or subcutaneous pellets.
1. Topical - Androgel®, Axiron®, Fortesta®, Testim®, Vogelxo®, transdermal patch-
Advantages -
- no injection or insertion procedure required
- bioidentical testosterone
Disadvantages -
- messy (creams or gels)
- expensive
- can be transferred via skin contact to your partner if it's not rubbed in adequately
- can be difficult to achieve optimal levels of testosterone because of inconsistent absorption
- not always covered by insurance
2. Injections - testosterone cypionate, testosterone undecanoate
Advantages -
- once weekly dosing
- usually covered by insurance
- relatively inexpensive
Disadvantages -
- requires weekly shots
- testosterone level varies greatly (high at first, low late in the week)
- may cause an elevation in red blood cells (erythrocytosis) - must be monitored
- synthetic testosterone
3. Subcutaneous Pellets -
Advantages -
- bioidentical testosterone
- lasts 6-7 months
- more consistent blood levels
- lower incidence of erythrocytosis
Disadvantages -
- expensive
- requires an office procedure to implant the pellets
- not covered by insurance
- slight risk of infection at the implant site
Women -
There are currently no pharmaceutical testosterone therapies for women.
However, there are still 2 treatment options that can be extremely beneficial:
1. Compounded bioidentical creams
Advantages -
- less expensive
- multiple compounding pharmacies available
Disadvantages -
2. Subcutaneous pellets
Advantages -
- lasts for 3-4 months
- consistent blood levels
Disadvantages
- expensive
- requires an office procedure to insert the pellets
If she has a history of breast cancer, she could receive testosterone pellets with anastrazole - but no estrogen.
Side Effects of Testosterone Therapy
When prescribed correctly, side effects are usually minimal. However, we are talking about a hormone, so it is possible to notice some changes. They may include:
- Increased hair growth on the face (usually the "peach fuzz" primarily
- Enlargement of the clitoris (women). Reverses when therapy is stopped.
- Erythrocytosis - increased hemoglobin and hematocrit. Usually mild. Treated with regular blood donation. CBC should be monitored.
- Mood Swings/Irritability - less common with bioidentical testosterone
- Water Retention - rare and usually only the first few weeks of therapy.
- Voice Changes - rare with bioidentical testosterone. Most commonly seen with anabolic steroids. Of note, 34% of women have voice changes as they age, so it may not be from the testosterone therapy.
- Injection Site Irritation or Infection - rare and usually mild
- Insertion Site Infection with Pellet Therapy - rare and usually mild
- Excessive Estradiol Conversion - Occasionally men will have an overactive aromatase enzyme which will convert the testosterone to estradiol. This can cause breast tenderness and mood swings. Treated with the supplement DIM or a medication such as Arimidex or Femara.
Summary
Testosterone is an important hormone in the body and is vital for well-being and energy.
Studies show that it helps prevent heart disease, dementia, osteoporosis, and possibly breast cancer.
When managed closely by an experienced provider, it is a safe and effective therapy for multiple symptoms associated with menopause, andropause, and the aging process.
Now it's your turn.
Do you think you have low testosterone?
Have you been tested?
Have you ever been treated for low testosterone?
Did testosterone therapy help you?
Leave your comments below!
