Treatment Of Low Testosterone

Medically Reviewed by Dr Sravya, MBBS, MS

Introduction

Low testosterone in males is a condition caused due to insufficient secretion of the male sex hormone testosterone. It is also known as male hypogonadism. It affects both males and females, however it is more common in males. Testosterone levels in males drop with increasing age, but low testosterone can also be the result of malfunctioning of hormone secreting organs. Treatment of low testosterone is known as testosterone replacement therapy (TRT), and can be administered in males as well as females.

Table of Contents

What is testosterone?

Testosterone is a sex hormone found in males and females and is secreted by their respective sex organs (gonads). In males, it is secreted by the testes, whereas in females, it is secreted by the ovaries. Testosterone plays an important role in maintaining physical and mental health in both sexes. If testosterone levels are reduced, it may cause several health problems. However, treatment of low testosterone is easily available for males and females.

The quantity of testosterone secreted in males is much higher than that in females. On average, an adult male produces seven to eight times more testosterone than an adult female.

Testosterone is an androgen. It means that it is responsible for the development of male characteristics such as deepening of voice, facial hair growth, and sperm development.

How is it produced?

Testosterone is secreted by the Leydig cells present in the testes. The secretion of testosterone is regulated by a negative feedback loop. This loop involves the hypothalamus (part of the brain which maintains the body’s stable state), the pituitary gland, and the testes.

When the levels of testosterone in the body run low, the hypothalamus secretes gonadotropin-releasing hormone (GnRH). The GnRH then stimulates the pituitary gland to secrete follicle stimulating hormone (FSH) and luteinizing hormone (LH).FSH and LH in turn stimulate the testes to secrete testosterone.

Once the level of testosterone is increased, the hypothalamus and pituitary gland are signalled to stop producing GnRH and FSH/LH respectively. This maintains normal testosterone levels.

Functions Of Testosterone

Testosterone has an important role to play in the development of males. It is a significant factor in maintaining their physical and mental health, as well as sexual and social behaviour. The most prominent functions of testosterone occur at three stages throughout the life of a male.

Before birth, testosterone is responsible for the formation of male reproductive organs, both internal and external. The descent of the testes through the inguinal canal is also dependent on testosterone. This is observed in the later stages of pregnancy.

During puberty testosterone production significantly increases. This causes primary sexual development in males. These changes include the formation of sperm, enlargement of reproductive organs such as the penis and testes, and increased libido (sex drive).
It also causes secondary masculine characteristics to develop. These include growth spurt, facial and pubic hair growth, deepening of voice, and excessively oily skin and acne.

In adulthood, testosterone is responsible for sperm production making them fertile. It also aids in the formation of new red blood cells, maintaining bone and muscle strength, and improving libido.

Normal Testosterone Levels

The doctor may ask about the symptoms and examine your scrotum to see if you have any infection symptoms.

They can also check your prostate for tenderness with a rectal exam. If these tests suspect epididymitis, then your doctor might ask for one or more tests. Such as,

High Testosterone Levels

Higher levels of the hormone do not usually cause any major health problems in adult males. However, it can be a risk factor for heart failure and may cause impulsive behaviour, hypersexuality, and male pattern baldness. Testosterone levels may be elevated due to tumours of the testes or adrenal glands. In male children with higher than normal testosterone levels, precocious puberty may occur. This means that the signs of puberty are seen before 9 years of age.

Low Testosterone Levels

Low testosterone levels, medically known as hypogonadism, is a condition where there is diminished secretion of testosterone in males. It is also known as testosterone deficiency syndrome. The American Urology Association (AUA) has determined that testosterone level is said to be low when it drops below 300 ng/dL. According to the AUA, around 2% of the total male population experiences low testosterone levels. Treatment of low testosterone is recommended in these cases.

Symptoms Of Low Testosterone

Deficiency of testosterone can manifest as different symptoms during different stages of life.

1. Foetal stage -

If testosterone levels are low during the development of a foetus, it causes a condition called Androgen Insensitivity Syndrome (AIS). It affects male foetuses. They are genetically male but are insensitive to male sex hormones. In teenagers, it deters proper development of genital organs and leads to infertility in adult males.

2. Puberty -

Low testosterone in pubertal age leads to stunted growth. Such individuals are short in height. Genital and reproductive organs do not develop fully. The deepening of the voice is less. Pubic and facial hair growth is reduced. Muscle and bone strength are affected.

3. Adulthood -

Low testosterone levels in adult males can cause erectile dysfunction and diminished libido. It lowers sperm count which may cause infertility. Increased body fat, hair loss from the scalp and body, enlarged breast tissue (gynaecomastia), depression, reduced muscle strength, and memory issues are also seen.

Causes Of Low Testosterone

Testosterone levels are reduced in males with increasing age. This is known as late-onset hypogonadism. The decrease in the production of testosterone can also be attributed to several other factors. Hypogonadism in males is caused due to two main reasons –

Either type of hypogonadism can be further classified into congenital (since birth) or acquired (developed later in life).

1. Primary hypogonadism -

It occurs when the testes are affected, and are unable to secrete required levels of testosterone. This condition is also called hypergonadotropic hypogonadism.

Congenital causes include absent testicles (anorchia), failure of testicles to descend into the inguinal canal (cryptorchidism), or genetic disorders such as Klinefelter’s syndrome or Noonan syndrome

Acquired causes include inflammation of the testicles (orchitis), injury to the testicles, surgical removal of testicles (orchidectomy), and radiotherapy or chemotherapy to the testicles.

2. Secondary hypogonadism -

It occurs when there is malfunctioning of the hypothalamus or pituitary gland. This condition is also called hypogonadotropic hypogonadism.

Congenital causes include isolated hypogonadotropic hypogonadism (a condition where gonadotropin-releasing hormone is deficient since birth) or genetic disorders such as Kallmann syndrome and Prader-Willi syndrome.

Acquired causes include hypopituitarism, Cushing’s syndrome, kidney disorders, liver cirrhosis, unregulated diabetes mellitus, head injury, HIV/AIDS, and obesity.

Diagnosis Of Low Testosterone Levels

If symptoms of low testosterone levels are observed, a doctor will prescribe some blood tests to confirm the diagnosis. These include –

1. Total testosterone level -

This test is done to check the level of testosterone in the blood. As testosterone levels tend to vary throughout the day, it is best to conduct this test in the morning for maximum accuracy.

2. Luteinizing hormone (LH) test -

This test is done to check pituitary gland function.

3. Prolactin test -

Increased levels of prolactin hormone may indicate issues of the pituitary gland or tumours.

If symptoms of low testosterone levels are observed, a doctor will prescribe some blood tests to confirm the diagnosis. These include –

Treatment Of Low Testosterone

The most widely used treatment for low testosterone levels is known as Testosterone Replacement Therapy (TRT). It should only be prescribed to those experiencing symptoms of hypogonadism and have testosterone levels lower than 300 ng/dL. TRT can also be used in females for the treatment of low testosterone. The dosage of these therapies varies from person to person, depending on the situation.

Testosterone can be administered in many ways, such as –

1. Injections -

Injectable testosterone can be short-acting or long-acting. The short-acting ones are given every 1-2 weeks. For the long-acting ones, there is a gap of 4 weeks between the first two shots and the rest are given every 10 weeks.

2. Topical gels -

Testosterone is applied in the form of cream or gel on the skin daily, and it gets absorbed gradually. Care should be taken to avoid transferring the gel to another person via direct contact.

3. Topical patches -

Testosterone patches are stuck on the skin every day. However, they may not suit those prone to skin allergies

4. Buccal patches -

These patches are placed on the inside of the cheeks above the upper teeth. They are applied twice a day. They may cause irritation to the gums in some people.

5. Implants or pellets -

A small plastic pellet is implanted under the skin by a doctor via a minor surgical procedure. The pellet dispenses testosterone over a period of 3-6 months.

6. Intranasal -

A testosterone gel is applied on the inside of the nose thrice a day, every 6-8 hours.

7. Oral -

Testosterone is given in pill form. However, it can have long-term damaging effects, so it is prescribed only to those who cannot use other forms of testosterone.

Conclusion

Low testosterone levels is a common disorder mainly in males, however it is also treatable. The treatment of low testosterone is testosterone replacement therapy, or TRT. If someone is experiencing symptoms of low testosterone, it is advisable to get a diagnosis. Once diagnosed, TRT can be administered to get the levels back to normal.

Frequently Asked Questions

What are the side effects of Testosterone Replacement Therapy (TRT)?

TRT has some side effects such as –
(i) Increased risk of heart disease
(ii) High blood pressure
(iii) Worsened sleep apnea
(iv) Decreased sperm count
(v) Male pattern baldness
(vi) Acne
(vii) Deep vein thrombosis
(viii) Swelling of hands and feet

Who should not undergo TRT?

TRT is contra-indicated in –
(i) Prostate cancer patients
(ii) Breast cancer patients
(iii) Obstructive sleep apnea patients