Testosterone Replacement
Testosterone deficiency syndrome (TDS) is a clinical and bio-chemical syndrome characterised by low levels of testosterone (below normal physiological levels) and characteristic symptoms and signs. It is particularly common in type 2 diabetics (40% of them) and overweight and obese men.
Research has found that average testosterone levels have decreased by 20% compared to what they were 20 years ago. It has been estimated that up to 1 in 10 men over the age of 50 have Testosterone Deficiency Syndrome (TDS). Unlike the menopause testosterone deficiency can have a more insidious, gradual onset and often goes undiagnosed. It is often confused with depression or just ‘getting old’.
Testosterone plays important roles in men. For example, this hormone influences aspects of short-term health like mood and sex drive, as well as being important for men’s long-term health by helping to maintain strong bones and a healthy body shape.
The Major Goal of
Testosterone Replacement Therapy:
“To achieve & maintain normal physiological testosterone levels to relieve symptoms of androgen deficiency, such as loss of libido, erectile dysfunction, changes in body composition and psychological impairment”
Assessment for TDS is based on medical history, specific male sexual health questionnaires and blood tests for hormone levels. An example of one such questionnaire is the ADAM questionnaire (see below).
The ADAM (Androgen deficiency in Ageing males’) questionnaire
- Do you have a decreased libido (sex drive)?
- Do you suffer from lack of energy?
- Have you noticed a decrease in strength and or/ endurance?
- Have you lost height?
- Have you noticed a decreased “enjoyment of life”.
- Are you often sad and/or grumpy?
- Are your erections less strong than they used to be?
- Have you noticed a recent deterioration in your ability to play sports or exercise?
- Do you find yourself falling asleep after dinner?
- Has there been a recent deterioration in your work performance?
If you have answered “YES” to question 1 or 7, or any 3 other questions, you may have testosterone deficiency syndrome.
Frequently Asked Questions
What is hypogonadism/testosterone deficiency syndrome?
Male hypogonadism (also known as testosterone deficiency) is defined as a clinical and biochemical syndrome associated with advancing age and comorbidities. It is characterised by a deficiency in serum androgen levels and relevant signs and symptoms, including low mood, fatigue, reduced muscle mass and decreased libido.
Testosterone has many effects on the body, including primary sexual development and regulation of secondary male characteristics. It’s important for a man’s physical and emotional well-being, including maintaining muscle and bone mass, the production of sperm and libido – amongst other things.
At what level of testosterone, in patients with testosterone deficiency, should your doctor consider treating you with testosterone replacement therapy?
Regarding the thresholds for treatment intervention in symptomatic men, the British Society for Sexual Medicine and International Society for Sexual Medicine guidelines recommend the following:
• A testosterone level lower than 8 nmol/L or free-testosterone level lower than 0.180 nmol/L based on 2 separate levels (taken from 8 to 11 AM) usually requires testosterone therapy.
• A testosterone level higher than 12 nmol/L or free testosterone level higher than 0.225 nmol/L does not usually require testosterone therapy.
• Testosterone level from 8 to 12 nmol/L might require a trial of testosterone therapy for a minimum of 6 months based on symptoms.
What assessments does your doctor need to carry out before initiating testosterone therapy and what are the monitoring requirements after treatment?
Testosterone deficiency should be diagnosed on the basis of:1,2
1. Signs and symptoms
2. One to two fasting Total Serum Testosterone tests on separate occasions carried out between 7-11am
Prior to testosterone initiation, all patients > 40 years old must undergo a PSA (prostate specific antigen) test or bring in a recent PSA blood test result to exclude a risk of pre-existing prostate cancer. Patients may need a blood test for luteinising hormone and prolactin. For patients experiencing gynaecomastia a blood test for oestradiol will need to be added.
Patients on testosterone will need follow up monitoring of bloods:
• PSA test and testosterone blood test at 3-6 months after starting treatment and then annually.
• Haematocrit, haemoglobin, testosterone, liver function, lipids and blood pressure should be monitored periodically
If I am diagnosed with testosterone deficiency syndrome how long will I need to be on testosterone replacement therapy?
Hypogonadism is a chronic disease which requires long-term treatment, not unlike diabetes. It is important to realise that testosterone replacement therapy is considered lifelong therapy
In patients who have a positive response to testosterone replacement therapy treatment should continue in accordance with a standardised blood monitoring plan to ensure safety.
For the continued long term protective effects of testosterone on muscle and bone mass, cardiovascular, sexual and mental health it is important patients are compliant with therapy and that the dose is optimised to be within the proper therapeutic range.
What are the different types of testosterone replacement therapy available?
The types of prescription testosterone therapy vary in terms of route of administration: gels and sprays applied topically, (Testogel, Androgel, Fortesta, Tostran, Natesto) short acting, medium acting and long acting injections, (testosterone cypionate, Sustanon, Xyosted (testosterone enathate), Nebido (testosterone undeconoate), pellets embedded under the skin and oral tablets.
Topical gels are the preferred route of administration in modern medicine:
The 2020 European Academy of Andrology (EAA) guidelines on investigation, treatment and monitoring of functional hypogonadism in males suggest the use of transdermal T gels, as the preferred preparation in the initiation of testosterone therapy due to the potentially reversible nature of functional hypogonadism
The 2021 Update from the European Association of Urology Guidelines on Sexual and Reproductive Health state that prescribers should use testosterone gels rather than long-acting depot administration when starting initial treatment, so that therapy can be adjusted or stopped in case of treatment-related adverse effects.
If fertility is important then a different treatment approach will need to be considered including Human Chorionic Gonadotrophin as testosterone therapy tends to reduce sperm count.
Does your clinic also treat erectile dysfunction?
Sometimes testosterone replacement therapy alone is enough to correct any pre-existing erectile dysfunction and oftentimes a combined approach is the most optimal for a patient. There are several different oral medications available, they have differing times for onset of action and duration of action such as Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), Spedra (avanafil). There are also various cream topical preparations. Information and advice will be given during your consultation and the best match to your needs and background health can be prescribed.
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