Low testosterone levels – known in some corners as “man-o-pause” – are one of the byproducts of aging; according to the American College of Physicians (ACP), an age-associated decline in total testosterone levels begins in men in their mid-30s and gradually increases by an annual average rate of 1.6%. The ACP reports that the incidence of low testosterone in the U.S. stands at about 20% in men older than 60, 30% in those older than 70, and 50% in those older than 80.
I see a fair amount of patients in their mid-50s and older who tell me about how they feel more tired, that their erections aren’t what they used to be, and how they have less interest in having sex with their partner. With some of those patients, tests show that their testosterone levels are totally normal, so I find myself telling them, “Welcome to middle age.”
But that is not always the case. On average, a testosterone level of 300–1,000 nanograms per deciliter (ng/dL) of blood is normal. Reduced testicular function is typically diagnosed when the total testosterone is less than 300 ng/dL.
Effects of declining testosterone levels can include a lower sex drive, erectile dysfunction, lack of energy, loss of muscle strength, moodiness and even depression. In some cases, the decline can be attributed to such factors as an injury to the testes, a pituitary gland issue, a history of cancer/radiation therapy, and/or a family history of stroke or heart attack. However, in many instances, the cause for this decline can be simply attributed to age. However, in most instances, the cause for this decline is idiopathic – that is, we simply don’t know.
Fortunately there are ways of addressing low testosterone for most men: testosterone replacement therapy (TRT). Offered by urologists and endocrinologists, TRT can take many forms: injections of testosterone cypionate (Depo-Testosterone) and testosterone enanthate can be done at home, usually bi-weekly, while those involving deep intramuscular injections of testosterone undecanoate (Aveed) are given at your provider’s office, usually every 10 weeks.
Note that Aveed is only available through your doctor’s office, clinic, or hospital, and therefore is not a medicine you can give yourself at home. You must also remain at the provider’s site for 30 minutes after injection so that the provider can watch for symptoms of POME or a serious allergic reaction. Symptoms of POME, or Pulmonary Oil Microembolism, include cough, difficult or labored breathing, chest pain, dizziness, and temporary loss of consciousness.
There are also a variety of topical creams, pills, nasal sprays – application frequency varies widely – and even implantable pellets, which involves your provider making a small incision, usually in the buttocks, every three to six weeks.
Quality of life usually improves within a few weeks, but the full effects of TRT can take three to six months. Patients tend to feel more energetic and can lose weight (with exercise and a proper diet), and see improvements in their sex drive. Pre-diabetic and diabetic patients can also benefit with improved insulin production.
However, there are side effects to consider. These can range from hair loss, acne and even breast enlargement to elevated red blood cell counts, changes in liver function, and in some cases cardiovascular issues, including heart attack and stroke. All of these will be discussed with your primary care physician and the TRT provider, and regular monitoring via blood and urine tests are necessary.
Interest in TRT continues to grow and, under the right circumstances, can make a very positive impact on one’s quality of life – physically, mentally and emotionally. Consult a provider to see if it’s right for you.
Dr. Aaron Hagge-Greenberg is a urologist and urologic surgeon at White Plains Hospital Physician Associates. For an appointment, call 914-949-7556.