Testosterone levels peak when men are in their 20’s. Levels inevitably start to decline at age 30, as much as 1% per year, or over 10% per decade. This is often referred to as andropause (though perhaps it should have been named menopause). Symptoms of andropause include:

Declining muscle and bone mass
Increased body fat, especially in the abdominal area
Loss of or low sex drive
Fewer spontaneous erections
Difficulty maintaining erections
Swollen or tender breasts
Flushing or hot flashes
Depression
Reduced self-confidence
Fatigue that worsens throughout the day
Sleep issues
Difficulty concentrating
Mood swings & irritability

Many of these symptoms describe female menopause. That’s because as male testosterone levels decrease, estrogen levels often increase. Men then take on the same hormone imbalance symptoms women face in menopause.

Over the past 30 years, we have started seeing lower testosterone levels occur in younger men. This may be due to exposure to environmental chemicals, being overweight, or poor nutrition, all of which can have a negative impact on hormone levels. Testosterone and estrogen are not the only hormones that can be affected. Progesterone, human growth hormones, DHEA, and other important hormones may also be impacted.

One of the reasons low testosterone often goes undiagnosed is that the “normal” results range is wide. Most labs consider normal levels to be between 220-1000 ng/dL. Many men are symptomatic under 400 ng/dl. The decision to start testosterone replacement therapy (TRT) is based both on labs and symptoms.

Benefits of Testosterone Therapy

Increased sexual drive, libido. Reduced erectile dysfunction
Reduced irritability, agitation, mood swings, and anger outbursts
Better ability to focus, concentrate and improved brain fog and memory
Increased muscle mass and strength coupled with exercise
Weight reduction, faster metabolism
More stamina, increased energy, and vitality
May reduce the risk for high blood pressure, high cholesterol, diabetes

Testosterone Replacement Therapy comes in several forms:

Skin patch (transdermal): Androderm is a skin patch worn on the arm or upper body. It’s applied once a day.
Gels: AndroGel and Testim come in packets of clear testosterone gel. Testosterone is absorbed directly through the skin when you apply the gel once a day. AndroGel, Axiron, and Fortesta also come in a pump that delivers the amount of testosterone prescribed by your doctor. Natesto is a gel applied inside the nose.
Injections and implants: Testosterone can also be injected directly into muscles or implanted as pellets in the soft tissues. Your body slowly absorbs the testosterone into the bloodstream.

There are two common types of testosterone injection prescriptions. They are considered safe and provide good results. The testosterone dose in each is the same, what makes them different is the chemical it is blended in. The chemical is known as an ester and determines the half-life or how long the testosterone can stay in your system, similar to a “time-released” formula.

Testosterone Cypionate– bio-identical hormone. Metabolizes in 7-8 days and is considered a long-acting compound.
Testosterone Enanthate– metabolizes in 4-5 days, small amounts may stay in the body up to 2 weeks.

Both are oil-based, meaning they are thick substances, administered intramuscular (IM) into a muscle, or subcutaneous (SC or SubQ) into the fatty layer under the skin. IM has been the most common route or delivery, but SC is proving to be superior. Testosterone delivered SC has proven to maintain stable levels with minimal to no side effects. IM injections are typically administered in the upper portion of the outer thigh or in the gluteal (buttocks) muscle. Subcutaneous injections are most often administered into the thigh, the abdomen (2”-3” inches to the right of the navel), or into the deltoid muscles. Rotating sites avoid tissue irritation.

A yearlong Canadian study regarding subcutaneous administration of testosterone in hypogonadal men investigated the efficacy of low dose testosterone. Results showed SC testosterone produced levels within the normal range in 100% of the patients (Al-Futaisi AM, Al-Zakwani IS, Almahrezi AM, Morris D. Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman).

Carrier Oils- standard testosterone prescriptions are mixed in a cottonseed oil base. This oil is thicker than other options and may cause allergic reactions in some people. The other two most common oils used are grapeseed and sesame seed oil. They tend to be thinner and cause less pain on injection. Grapeseed and sesame oil formulas have to be ordered from a compounding pharmacy and may not be covered by your insurance.

If you decide to stop testosterone therapy you must reduce your dose gradually over time. Abruptly discontinuing treatment may produce withdrawal reactions such as depression, weakness, and fatigue.

Caution- do not use testosterone therapy if you have or have had prostate or breast cancer. Chronic diseases such as diabetes, heart disease, liver or kidney problems, an enlarged prostate may require special dosing consideration. Testosterone may decrease glucose blood level which interferes with diabetes medications. It may also increase the effectiveness of blood thinners.

Lab Testing

Ideally, testosterone labs take place between 7 am-11 am when testosterone levels are typically the highest

CBC (complete blood count) and PSA- we’re going to monitor your hematocrit, hemoglobin, and PSA while you’re on “T” therapy.

CMP (comprehensive metabolic panel)- we’re checking liver function

Male Hormone Panel– Estradiol (E2) and estrone (E1), Testosterone Free and Total, Progesterone, Sex hormone-binding globulin (SHBG), DHEA-S. Some or all of these may be ordered depending on each man’s case.

Ideal Male Hormone Levels

Total testosterone 700-1000 ng/dl
Free Testosterone 250-300 pg/ml
Estradiol 20-30 pg/ml, teens and young men may be as high as 90pg/ml
SHBG 10-30 nmol/l
DHT 60-70 ng/dl
Prolactin 2-3 ng/ml
DHEA-S ~300 ug/dl
LH- 1.86-8.6 IU/L
FSH- 1.5-12.5 mIU/ml

Testosterone therapy needs to be adjusted to reach optimal hormone ranges. So, in the beginning, you may need to have blood tests every 4-6 weeks. But symptomology outweighs the target numbers. Our objective is to reduce symptoms associated with low testosterone.

Notes:

- Peppermint and spearmint may decrease testosterone levels.
- Cannabis may decrease testosterone in men.
- We will rigorously screen you for prostate enlargement and/or cancer.