Testosterone Deficiency Syndrome or TDS refers to an age-related decline in testosterone resulting in various clinical symptoms. It is sometimes referred to as “andropause” or “male menopause” however unlike female menopause, this process is rather gradual.
1) What is testosterone?
- This is a hormone produced primarily in the testicles.
It serves many functions including:- Libido and sexual function e.g. erection.
- Maintenance of muscle and bone mass.
- Ensures adequate energy levels, supports mood and well-being.
- Healthy sperm production and fertility.
2) How do testosterone levels change with age?
- Levels peak between early 20s to around 35 years.
- Above 35 years, these levels gradually decline.
- Between 40-79 years of age, testosterone levels fall between 0.4-1% per year.
- Above 80 years, this decline is more marked.
3) What are the symptoms of TDS?
There are many and your doctor may give you a 17-item questionnaire to fill out called the Aging Male Score or AMS. This will help them in the diagnostic process.
- Loss of libido or sex drive.
- Erectile dysfunction meaning the inability to initiate or maintain an erection.
- Decreased spontaneous or morning erections.
- Increased fatigue and reduced energy levels.
- Depressed mood or increased irritation.
- Loss of muscle mass and weight gain.
Other symptoms to be considered are thinning of hair, decline in cognitive function, reduced skin elasticity, fractures as a result of reduced bone density or osteoporosis.
4) How is TDS diagnosed?
2 main criteria are required for diagnosis:
- Presence of symptoms and
- Laboratory evidence of low testosterone levels.
Blood draw takes place ideally fasted between 7 and 11am. This is due to variations in levels during the course of the day.
Typical blood tests ordered are total testosterone and protein levels. Other hormones may be included if there is suspicion of other causes of symptoms.
5) There are other possible conditions that may mimic TDS e.g.:
- Thyroid conditions.
- Elevated prolactin levels (produced in the brain).
- Chronic diseases e.g. diabetes, hypertension, high cholesterol especially if suboptimally controlled.
- Mood disorders like depression.
- Psychosocial factors like stress and relationship issues.
6) When do we initiate treatment if a man is symptomatic?
- If total testosterone levels lie below 8 nmol/l, most men will benefit from testosterone replacement.
- Levels above 12 nmol/l do not typically require treatment.
- Levels between 8 and 12 nmol/l require calculation of free testosterone before deciding if hormones may be beneficial.
7) How is testosterone replaced?
- Generally, a trial period of 3 to 6 months of testosterone replacement therapy (TRT) is advised.
- Oral medication may be considered, these are taken daily. The problem with this method is that testosterone levels may fluctuate with the variable amount of dietary fat consumed.
- Topical gels or patches are other options. Gels have to be applied daily and caution taken when in contact with children or women. A period of 4 hours is therefore advised before any skin to skin contact or swimming.
- Injections come in short- vs long-acting forms.
Short-acting TRT is given once to twice weekly and usually associated with peaks and troughs in levels.
Long-acting TRT is most favoured. 2 doses are given intramuscularly over 6 weeks and subsequently every 3 months.
Note: The method chosen depends on patient’s preference, levels of testosterone and cost.
8) Treatment of accompanying symptoms and conditions.
- Erectile dysfunction may require the addition of medications like PDE5 inhibitors. Common drugs that fall under this category are Viagra or Cialis.
- Management of cardiovascular risk factors like hypertension and high cholesterol with lifestyle modifications (regular exercise, smoking cessation and stress management) as well as initiation of medication.
- Mental health issues may require counselling and at times addition of anti-depressants.
9) Not everyone with low testosterone is a suitable candidate for TFT. Who should not be started on hormones?
- History of prostate, breast or liver cancer.
- Patients who are not done with family planning and wish to preserve fertility.
- Certain blood conditions e.g. polycythaemia rubra.
- Severe heart failure, liver or kidney disease.
- Severe obstructive urinary symptoms which may indicate an underlying prostate condition.
- Uncontrolled high blood pressure or cholesterol could worsen with TFT.
- Untreated severe obstructive sleep apnoea.
10) Though potential side-effects of TFT are many, most men do not experience any of the following:
- Local effects if using injections – pain/bruising at injection site.
- Acne and oily skin.
- Hot flushes.
- Mood changes.
- Thickening of the blood due to increased red blood cells.
- Mild fluid retention in the form of ankle swellings.
- Worsening of urinary symptoms.
- Thinning of the hair.
- Breast tenderness.
- Infertility caused by negative feedback mechanism in the brain leading to reduced sperm production.
Note that contrary to earlier reports, testosterone replacement does not lead to an increased risk of cardiovascular disease. It does not increase the risk of developing prostate cancer either.
11) How is treatment monitored?
Initially every 3 to 6 months, subsequently annually. Your doctor will be looking out for the following:
- Symptom improvement – libido, sexual function, mood, energy levels.
- You will be asked about side-effects.
- Blood tests will be done to monitor your hormone levels, haematocrit (determinant of how thick your blood is), PSA (prostate specific antigen).
- Prostate examination.
- Cholesterol, glucose and blood pressure will be monitored annually.
- A bone mineral density may be ordered depending on your risk factors.
12) What is the duration of treatment?
- Short term treatment between 3 to 6 months if lifestyle changes have had a positive effect on symptoms and overall well-being.
- Cyclical treatment refers to being on hormone replacement but coming off for short periods before re-starting treatment. This may be a patient’s preference.
- Most men however continue on testosterone for longer periods, or indefinitely.
