Testosterone Deficiency – Causes and Diagnosis

Causes of Testosterone Deficiency

Male hypogonadism is the medical phrase used to describe men with a testosterone deficiency. The severity of the condition can vary from individual to individual. However, there is universal similarity of symptoms in men with testosterone deficiency. These include:

• fatigue
• lethargy
• lack of motivation
• poor memory
• mood changes
• ill temper
• depression
• sexual dysfunction
• poor erectile function
• loss of sexual interest
• diminished muscle strength
• osteoporosis
• anaemia

Male hypogonadism is most caused by 3 circumstances: testicular damage, disease or a genetic disorder like primary hypogonadism) e.g. Klinefelter’s syndrome. It may also result from malfunctioning of the pituitary gland or hypothalamus in the brain (secondary hypogonadism).

Primary and secondary hypogonadism has a prevalence of 5 cases per 1000 men. This makes it one of the most common forms of hormonal deficiencies in men, yet only one in five men are diagnosed early in life.

Testosterone replacement therapy (TRT) effectively restores blood testosterone concentrations in men with hypogonadism to the normal levels of healthy young males. Common causes that result in less testosterone being produced production  and resulting in a deficiency state include:

Testicular Disorders
• Klinefelter’s syndrome
• Cryptorchidism and defects of testis development (twisted or strangulated testes)
• Orchitis (Inflammation of the testes resulting in permanent damage)
• Orchidectomy (surgical removal of the testes)
• Toxin exposure (radiation, chemotherapy or radiotherapy, domestic, industrial or environmental poisons)

Brain Disorders (Hypothalamic-Pituitary Dysregulation)
• Kallmann syndrome (a genetic disorder)
• Other genetic causes
• Pituitary gland tumour and treatment (surgery and/or irradiation)
• Haemochromatosis (blood iron disorder)
• Craniopharyngioma (benign tumour of the brain)

External Factors
• Acute critical illness, burns, major trauma or surgery
• Drug use (e.g., opiates, glucocorticoids, anabolic steroids)
• Chronic disease and its treatment
• Alcohol abuse
• Smoking
• Ageing

More recently, a third class of hypogonadal men have been identified and defined. The late-onset hypogonadal male is the largest under diagnosed group of all testosterone deficient individuals. This group consists of middle-aged and older men who exhibit symptoms associated with lowered testosterone levels and who’s condition is not associated with primary or secondary hypogonadism. This is one of the most rapidly expanding areas of medical practice. Recent medical studies show as many as 37% of all men over the age of forty have symptoms of testosterone deficiency.

The late-onset hypogonadal male’s symptoms are often non-specific. They include lethargy, sleep disturbances, loss of libido, irritability, anxiety, reduced concentration and depressed mood. A testosterone blood test will often show results at the bottom end of the “normal” range. This may often result in a medical practitioner prescribing antidepressants to treat symptoms rather than the underlying cause. Diagnosing the symptoms which many men experience due to late-onset hypogonadism can be further complicated by pre-existing medical conditions. If a man suffers from obesity, diabetes or another chronic illness then it can be harder to realize that some of their symptoms related to low testosterone.

Regardless of the underlying cause of the testosterone deficiency, the best treatment is hormone replacement therapy. Testosterone replacement therapy (TRT) aims to restore circulating testosterone concentration to within the normal healthy male range with the absence of symptoms. TRT can resolve most, if not all, symptoms of low testosterone.

Complete the Testosterone Deficiency Assessment Test to see if you suffer from low testosterone.

 

How is Testosterone Deficiency in Men Diagnosed?

If a man exhibits low testosterone blood levels together with a range of relatively severe symptoms, then testosterone replacement therapy is vbeneficial.
Symptoms

Many symptoms associated with testosterone deficiency in men appear unrelated and many doctors fail to identify the root cause of suffering - testosterone deficiency. Experienced docotors will use an assessment questionnaire such as this  Testosterone Deficiency Assessment Test before sending your for further tests. this one can be done for free, online, without the help of your doctor. (sometimes it’s good to get a head start before consulting with your doctor. It can never hurt to do your own research)

The test is in the form of a questionnaire. There are 17 simple questions when you need to self-rate your answers. The questionnaire is based on 3 key areas – mind (5 questions), body (7 questions) and sexual (5 questions). Each response is assigned a rating. Total scores can range from 17-85. If your get a rating of over 50 then your symptoms of low testosterone are considered severe.

The questionnaire is well suited to assist in both the diagnosis of testosterone deficiency and for the monitoring of treatment in patients using testosterone replacement therapy.

Whatever the reason for low testosterone, the signs and symptoms as a result of testosterone deficiency are consistent.

Here’s a list of symptoms relating to Testosterone deficient men (not all the symptoms may present themselves in every case)
• Changes in mood (fatigue, anxiety, depression)
• Decreased body hair  and feminisation
• Decreased bone mineral density/osteoporosis
• Decreased body mass and decline in muscle strength
• Decreased libido and erectile quality
• Increased abdominal fat
• “Manboobs”, rudimentary breast development
• Low or zero sperm in the semen

Gauging the severity of symptoms via the use of the rating scale provides a yardstick for both patients and doctors to measure the success of testosterone treatment.
Blood Testing

Blood testing is important so you can determine the measurement of testosterone levels in the blood.It’s the most accurate way to decipher the level of testosterone deficiency.

Testosterone secretion rises and falls over 24 hours. This is known as a diurnal rhythm. During the night, testosterone production occurs and the early morning sees the highest blood testosterone levels.  This explains why many men experience erections upon waking up. During the day, serum testosterone levels slowly decrease and by the late afternoon and early evening they are at their lowest.

Therefore, blood samples should preferably be taken in the morning when testosterone levels are at their highest. Time of day, medication, stress, illness or recent surgery/trauma can all affect the level of testosterone.

The testes do not store testosterone. Once produced, testosterone is secreted into the blood stream where it is rapidly adhered to by the protein sex hormone-binding globulin (SHBG). SHBG is a transporter protein found in the blood. It acts as a carrier to move hormones around the body. Up to 99% of testosterone produced is bound to SHBG and inactive. Testosterone to which SHBG does not attach is the biologically available testosterone that is free to act on and enter into cells throughout the body. This “free testosterone” is crucial in determining how efficiently testosterone can have an impact upon the cells and tissue of the body.

Some doctors will measure only total testosterone levels (i.e. both free and SHBG bound testosterone). Measuring total testosterone does not take into account the SHBG levels so the total testosterone measurement alone is not an entirely accurate representation. How much testosterone is free to act in the body also needs to be accounted for. Also, pathology laboratories determine “normal” and “low” testosterone without taking into account the effects of SHBG. Age, alcohol, smoking, insulin and some prescription medications can elevate SHGB levels so it’s an important to factor that in during the diagnostic stage.

It is always best to measure both the “total” and the “free” or “calculated free” testosterone in the blood if the lab has the technical capacity to do so. An alternative option which takes into account SHBG levels is the “free androgen index” or FAI. This is calculated by the total testosterone level in the blood divided by the SHBG level multiplied by 100. Pathology labs do this automatically and the results are displayed as the FAI reading. An FAI reading of 75 or below strongly indicates testosterone supplementation is needed. Also, if the AMS score is also high.

It is essential the diagnosis and a decision of whether to use testosterone is NOT made on the result of a blood test alone. Nearly all men with a total or free testosterone result at the low end of the normal range and experiencing symptoms will positively respond to testosterone replacement. They will also achieve a significantly improved quality of life. Unfortunately, too many doctors see a reading in the “normal” range and dismiss testosterone as a treatment option. All too often antidepressants are prescribed. This achieves little by way of elevating mood and usually results in a more rapid decline of sexual function.

 

Further Reading:

What is Testosterone?

Testosterone Replacement Therapy  (TRT)

Potential Risks of Testosterone Treatment

Testosterone Online Self-Assessment Questionnaire

Testosterone for Men – Quick Q & A

The information in this article has been taken with permission from the official Lawley booklet on Understanding Testosterone in Men