Low Testosterone in Men: Diagnosis and Treatment

9 min read
Low Testosterone in Men: Diagnosis and Treatment

Testosterone is a word that’s commonly associated with caveman-like and brutish behavior. People hear the word and think of intimidating muscular men lifting weights or aggression fuelled fist fights. In reality, testosterone’s link to badly behaved males is often exaggerated by the media and is more of a misconception than a fact.

The actual role of testosterone is far more complex. It governs the development of the male genitalia, the growth (and loss) of hair, dictates the strength and size of bone and muscle tissue, and also plays a vital part in sperm production and libido.

In order for the sex hormone to successfully do its job, men need to be able to produce an adequate amount of testosterone.

Unfortunately, not everyone is able to produce enough testosterone naturally.

Men who fit this description are considered to have a testosterone deficiency, also referred to as low testosterone and known as hypogonadism. This article explores the effects of hypogonadism, its diagnosis, and the available treatment options.

What is testosterone?

Testosterone is the male sex hormone responsible for their development both sexually and physically. Testosterone leads to a deepening of the voice, muscle, and bone development, the growth of pubic hair, and the production of DHT (a hormone linked to hair loss in men).

It is also heavily linked to sexual function and therefore a normal testosterone range is important for preventing sexual dysfunctions.

Examples of these include erectile dysfunction and a low sperm count.

Do men and women have testosterone?

Yes, men and women both have testosterone. Females produce testosterone in the ovary, adrenal gland, and within peripheral tissues, while men produce testosterone in the testicles. Testosterone plays a similar role in men and women and is responsible for developments such as bone and muscle density. Although both produce the hormone, men have far higher levels of testosterone than women. Research shows that men can have up to 15 times more testosterone when compared to women of a similar age. 

What are the main symptoms of low testosterone?

The symptoms below have been linked to low testosterone, but it’s worth noting that these symptoms have a variety of causes and may not be indicative in isolation. If you believe you may have hypogonadism, consult a medical professional for further guidance.

Diagram on the Main Symptoms of Low Testosterone

Erectile Dysfunction (ED)

Erectile Dysfunction describes a condition in which men are unable to maintain an erection sufficient enough to be able to have sex. Numerous studies have shown the powerful effects of testosterone on penile erection, suggesting a close link between testosterone and ED. Since then, ED guidelines from the European Association of Urology have advised that all men presenting with ED should have their testosterone levels checked.

Reduced Sex Drive

An individual’s testosterone levels has the ability to affect their sex drive. As hormone levels fluctuate over a person’s lifetime, it’s possible that their sexual desire can be adversely affected. It should be noted that testosterone levels are just one of the causes of a reduced sex drive, alongside other factors such as stress, lack of sleep, or relationship difficulties.

Low Sperm Count

A low sperm count can also be an indicator of low testosterone. According to research, men who have a low sperm count can be up to twelve times more likely to have hypogonadism. The same research suggested that a low sperm count could be considered an indicator of an individual's overall health. One of the most devastating impacts of a low sperm count is the possibility of infertility.

Reduction in Testicle Size

Testicle size may be associated with an individual's testosterone levels and could be a result of a low sperm count. A study found that the volume of an individual's testicles correlates to semen profiles such as sperm density and sperm count. The same study stated that patients with a testicular volume of less than 20ml have an absence of sperm while an indicator of regular testicular function is roughly 30ml.

Sleep problems

Although sleep difficulties can arise for various reasons, some men who experience poor sleep quality could have a testosterone deficiency. The effect of testosterone on sleep can be detrimental in both extremes; men who don’t have enough testosterone can experience sleeping difficulties, while those who have too much (for example anabolic steroid users) can also struggle with sleep abnormalities.

Low testosterone causes

Diagram on the Low Testosterone Causes

Testicle injury

With the testicles located outside of the abdomen, they are susceptible to injury. Testicular damage can occur in a range of settings, from sports activities to workplace accidents. In most cases, damage to the testicles causes short-term pain. However, the lasting results can be far more damaging. Testicular damage can affect the amount of testosterone men are able to produce long-term and can even affect their fertility.

Testicular Cancer

Due to the aggressive nature of testicular cancer, there’s a possibility that patients will experience low testosterone as a result. Some of the possible reasons for a testosterone deficiency following testicular cancer can be due to damage to the cells which produce testosterone, orchidectomy (surgical removal of testicles), chemotherapy, and hormone changes from stress. It’s been reported that approximately 20% of testicular cancer survivors experience low testosterone after orchiectomy (surgical removal of the testicles).

Thyroid disorders

Thyroid disease is a term used to describe conditions in which an individual's thyroid isn’t making the right amount of hormones. Thyroid conditions such as hypothyroidism are known to reduce the amount of testosterone in men. Having been used for many years, thyroid hormone replacement can be used to normalize testosterone levels.

Diabetes

There is a significant relationship between low testosterone and diabetes. Men who suffer from type 2 diabetes are twice as likely to suffer from low testosterone compared to men who do not. For overweight men with type 2 diabetes and low testosterone levels, research states that implementing lifestyle habits such as weight loss and exercise can offer a range of health benefits. One of the benefits includes a potential increase in testosterone levels.

HIV / AIDS

There is an association between both untreated and treated HIV with low testosterone. Although it’s said that the symptoms of low testosterone are a common factor in HIV, diagnosing the condition can prove difficult due to the complexity of symptom attribution. Furthermore, the extensiveness of hypogonadism within HIV patients is debated due to the diagnostic criteria.

Obesity

The wider health implications of obesity are well documented, some of which include an increased risk of diabetes, heart disease, and some types of cancer. However, not everyone is aware of the link between obesity and low testosterone. Research suggests that both moderate and severe cases of obesity are linked to low testosterone, with the relationship between them considered bidirectional. In other words, low testosterone levels can be a predictor of obesity, and obesity itself can be a cause of low testosterone.

Lifestyle habits

An individual's lifestyle choices can affect their testosterone levels. For example, men who consume excessive alcohol may be at an increased risk of hypogonadism, with research stating that alcohol is associated with lower testosterone as well as altering other reproductive hormones. Other lifestyle habits such as a lack of exercise, excessive food consumption, and a high BMI can all lead to low testosterone.

Most common low testosterone treatments

Although some people can increase their testosterone levels by altering lifestyle habits, many individuals will require therapy to make up for their lack of natural testosterone production. This is known as testosterone therapy (TT) or testosterone replacement therapy (TRT).

Testosterone therapy can be performed using a variety of treatment techniques, each of which has different administration methods and associated risks.

The main testosterone therapy treatments are highlighted in the table below:

 TREATMENTS DESCRIPTION RISKS
Injections Testosterone cypionate and enanthate are administered via injection.

Testosterone undecanoate is given by intramuscular injection approximately every 10 weeks.

- Post-injection pain

- Infection of injection site

      Gel Gels are applied by rubbing them onto the skin, with multiple locations of application (including arms, shoulders, and thigh areas).

      Users will need to avoid cleaning the applied area for a few hours after use to prevent the removal of gel.
      - Mild skin irritation

      - Severe skin reactions

      - Medication spreading to others through skin contact

      - Limited absorption if the gel is removed
          Patches Testosterone patches are applied to the skin which absorbs the testosterone.

          Like gel treatments, users should be careful not to bathe or wash the bodily area containing the patch too soon after application
          - Same as above (skin reactions, medication spread and risk of limited absorption)
            Gum and Cheek This method utilizes the body's ability to absorb substances using the buccal cavity (above top teeth).

            A small testosterone pack is tucked in front of the top gum line and is absorbed into the patient's bloodstream.
            - May irritate the skin of the gums
              Implants Testosterone pellets known as Testopel are implanted via a surgical incision under the skin at regular intervals.
              - Insertion site infection

              - Pellets becoming loose
                  Nasal Testosterone gel is administered via the nostrils and must be applied twice for each nostril up to three times each day.

                  This method is higher maintenance than administering gel to other body parts but can reduce the risk of gel spreading to other people.
                  - Mild skin irritation

                  - Severe skin reactions

                      The main risks of testosterone therapy

                      Although testosterone therapy can vastly improve an individual’s quality of life and reduce some of the symptoms of low testosterone, the therapy does come with risks. The table above identified the risks associated with each type of application. However, there are general risks of testosterone therapy that you should be aware of before considering it as a treatment option. Some of these risks are highlighted below.

                      Acne

                      Acne causes spots (often in large quantities), and oily skin and can even lead to physical pain and discomfort. An article stated that the clinical application of testosterone, such as injections, pellets, and gels, can be linked to testosterone-induced acne. Due to physical changes in the appearance of individuals suffering from acne, it’s possible that physiological issues may develop such as low self-esteem.

                      Breast tissue development (Gynecomastia)

                      Gynecomastia is a side effect that can occur as a result of testosterone replacement therapy. This describes an increased amount of breast tissue in males developing as a result of the hormonal imbalance between estrogen and testosterone. Gynecomastia can occur in one or both breasts and can lead to visual differences in the appearance of the male breast, as well as tenderness or physical pain.

                      Sleeping difficulties

                      Men who are receiving testosterone therapy may also find that their quality of sleep is affected because of treatment. Obstructive sleep apnoea refers to when an individual's breathing stops and restarts during sleep. A study suggested that some men who had testosterone therapy subsequently experienced sleep apnoea, or found that it worsened their pre-existing symptoms of sleep apnoea. Sleep apnoea requires treatment as it can lead to further complications including strokes, heart disease, and diabetes.

                      Sperm count reduction

                      A potential side effect for individuals undergoing testosterone therapy is a reduction in their sperm count. When testosterone is administered from an external source, the production of other hormones such as the luteinizing hormone and follicle-stimulating hormone can be affected. As a result, it’s possible that the amount of sperm produced by the testicles is reduced.

                      Decreased testicular volume

                      Individuals who undergo testosterone therapy may find themselves noticing a difference in the appearance of their testicles, specifically in terms of size. Research states that a reduction in the volume of the testicles can occur as a direct result of lowered sperm production when testosterone enanthate is administered via intramuscular injection.

                      Low testosterone FAQs

                      Is there a link between COVID-19 and low testosterone?

                      Although research on the topic is limited, it does suggest that there could be a link between COVID-19 and low testosterone. A study that explored the testosterone levels of individuals with covid found that 55% of 121 men who made a recovery from confirmed COVID-19 had testosterone levels that indicated they may have hypogonadism.

                      Is there a relationship between exercise and testosterone levels?

                      Yes, research suggests that there is a relationship between exercise and the production of testosterone. In particular, a study found that men experienced a significant increase in testosterone levels after completing resistance training.

                      Summary

                      Hypogonadism is a condition in which an individual's body is unable to produce a normal amount of testosterone. There are a variety of symptoms of low testosterone, including ED, low libido, and sleep difficulties.

                      It’s worth noting that many of the symptoms of low testosterone have other causes which are often more prevalent and may make identifying the condition a challenge.

                      The causes of low testosterone can range from testicular injury to diabetes and obesity. The most used treatment for the condition is testosterone therapy, whereby testosterone is administered to individuals via methods including injections, gels, or patches.

                      This article is written for informative purposes and cannot be considered a substitute for professional medical advice. If you believe you may be suffering from low testosterone, consult a medical professional for further advice.

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