But the truth is that low testosterone has specific markers, and proper, supervised treatment may only be helpful for certain people. Testosterone supplements, methyltestosterone although these supplements are not suitable to treat late-onset hypogonadism. Testosterone replacement therapy (TRT) can help restore some affected functions of low testosterone. Treatment will require androgen replacement therapy, depending on the underlying cause and age of onset. It's unclear whether testosterone therapy has any benefit for older males who have low testosterone but no testicular or pituitary problems. This is when your testosterone levels are usually at their highest. If you are having difficulty becoming pregnant, you may want to talk to your doctor about the possibility of low testosterone levels. You may have a greater drop in your testosterone levels if you have long-term medical conditions or if you are living with obesity. It suggests that males don't have enough testosterone as they get older, however there is no clear evidence that this is a problem in healthy people. What Is Low Testosterone? Symptoms, Causes, Diagnosis, Treatment, and Prevention “Men who are carrying more fat are more vulnerable to extra conversion of testosterone to estrogen because that conversion occurs more in fatty tissue than in other kinds of body parts,” says Chubak. Body fat contains an enzyme called aromatase that converts testosterone into estrogen, causing hormonal imbalance. Other causes of primary hypogonadism include complications from the mumps and physical injury to the testicles or ovaries. (Males normally have one X and one Y chromosome, while females have two X chromosomes.) Signs of low testosterone (hypogonadism) in men can relate to sex, energy and physical changes Another meta-analysis of RCTs performed by Cai324 concluded that testosterone therapy in diabetic men improved fasting glucose levels (mean difference -1.1 points), fasting serum insulin levels (mean difference -2.73), and HbA1c (mean difference -0.87). In men with testosterone deficiency, testosterone therapy results in increased lean muscle mass and reduced fat mass, but no overall changes in BMI. Patients with anemia, both unexplained and explained, can increase their Hb and/or Hct levels while on testosterone therapy. In 2013, the AUA published the Early Detection of Prostate Cancer Guideline,222 which makes no specific statements about PSA screening in men with testosterone deficiency or in men on testosterone therapy. In men with elevated Hct and low/normal on-treatment testosterone levels, measuring a SHBG level and a free testosterone level using a reliable assay is suggested. Thus, pituitary dysfunction can develop after radiation therapy for sellar, parasellar, and extrasellar neoplasms (e.g., craniopharyngiomas, meningiomas, germinomas, chordomas, hemangio-pericytomas, pituicytomas, gliomas), head and neck tumors, and following total body irradiation for systemic malignancies. In homeostasis, LH levels are typically low. Serum testosterone and the downstream hormone E2 are involved in the feedback mechanism to the hypothalamus and pituitary to suppress LH production. The pituitary gland sits in the sella turcica below the cerebrum and plays a critical role in testosterone physiology by producing luteinizing hormone (LH), which targets the Leydig cells in the testes stimulating them to produce testosterone. As such, all patients who have a history of unexplained anemia should have their testosterone tested. Long-acting IM testosterone injection may also result in higher rates of polycythemia when compared to topical therapies, which is consistent with other short-acting IM testosterone therapies. Mild level adverse events specific to SQ pellet insertion includes polycythemia (48-50%), ecchymosis (32-36%), tenderness (20-32%), pain (28-29%), and swelling (16-18%), all of which resolve by 4 months post-insertion.446 Moderate level adverse events were less common (e.g., pain 3%, erythema 3%, ecchymoses 7%) and improved within 1 week. These recommendations, however, are not based on current testosterone pellet formulations and contrast with pharmacokinetic data available. Paul Turek, MD, a urologist in San Francisco, is an international leader in male fertility research.If a baby's body doesn't make enough testosterone while in the womb, it can affect the outer sex organs.Here, we’ll discuss the role of testosterone in men’s bodies, signs and symptoms of low levels, how a doctor can help and more.A study looking at the Adolescent and Young population utilizing the National Health and Nutrition Examination Surveys (NHANES) demonstrated a statistically significant increase in BMI from 1999 to 2016.A systematic review of the published literature was conducted to answer these key questions and provide the evidence base for the guideline.Hypoandrogenism is a common diagnosis in older men because the aging testis loses its ability to produce adequate levels of T despite normal or unchanged levels of LH (3).However, when levels drop too low, it can lead to a condition called hypogonadism, which significantly impacts quality of life.If a person suspects they have hypogonadism, a doctor can make a diagnosis by asking about medical history, conducting a physical exam, and ordering blood tests. Prior to offering testosterone therapy, clinicians should measure hemoglobin and hematocrit and inform patients regarding the increased risk of polycythemia. Men with testosterone deficiency who are interested in fertility should have a reproductive health evaluation performed prior to treatment. Serum estradiol should be measured in testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy. Also, it was intended for a specific audience of European genitourinary surgeons and is not easily accessible to most Canadian health professionals. More information on advantages and disadvantages of available products, including costs, is outlined in Tables 7 and 8 of Appendix 1. Compounded testosterone products are available at many compounding pharmacies in Canada, but there are no published data on the safety and efficacy of these products. A persistent failure to respond to testosterone supplementation requires a reassessment of the diagnosis or consideration for referral to a more specialized facility. Despite their economy and ease of administration, their availability on the Internet and the opportunity they provide patients to self-diagnose, the questionnaires cannot be relied upon in the absence of confirmatory history, physical findings and laboratory test results. Well-established reference ranges constitute the essential basis for identifying whether the circulating levels of a particular analyte, testosterone in this case, are normal or low. An overview of the assays available to aid in the diagnosis of testosterone deficiency is available in Table 4 (See button below). A review by Millar et al.4 searched MEDLINE and Embase databases from January 1966 to July 2014 for studies that compared clinical indication of low testosterone along with a measurement of serum testosterone in men. Considerable variation in dosages and in ingredients results. In contrast to commercial pharmaceutical manufacturing, which is regulated by the FDA, compounded medications are regulated by state laws and, therefore, vary significantly from one region to another.405 While testosterone gels and creams are the most commonly used forms of compounded testosterone therapies and are routinely less expensive than branded forms of testosterone, these preparations by individual pharmacies occur without direct FDA oversight and approval. Despite these effects, neither treatment led to significant changes in semen parameters.403 SERMs are oral agents that block E2 feedback resulting in increased LH secretion. One study from the Boston University School of Medicine found that more than 6 out of 10 men over age 65 have testosterone levels that are below the average levels of men ages 30 to 35. Aging As males age, their testosterone levels may naturally decrease by about 1 percent a year after age 40. This guideline is largely in agreement with the Endocrine Society’s clinical practice guideline on testosterone therapy in men with androgen deficiency syndromes published in 2010,2 which was a thorough, evidence-based assessment using the GRADE system to define the quality of the evidence and the strength of the recommendations. The authors found no statistically significant difference in serum total testosterone levels across the cohorts grouped by decades of age. The only way to know for sure, though, is to get a blood test to assess your hormones (including free and total testosterone levels). “But if you're talking about long-term risks in patients who have hypogonadism, it would make sense to optimize their vitamin D levels, because that would help with their bone health.” Men who have had exposure of their testes during radiation therapy, either through direct or scatter radiation, are possibly at risk for low testosterone and the Panel recommends total testosterone measurement in such patients.Testosterone replacement therapy (TRT) can help restore some affected functions of low testosterone.There are many reasons that you may have low testosterone levels.This article, targeted to primary care physicians, reviews the concept of late-onset hypogonadism, describes how to determine the patients who might benefit from therapy, and offers recommendations regarding the workup and initiation of treatment.For example, a particular study might show that testosterone therapy is correlated with a statistically significant improvement in the IIEF scores in a given population; however, the clinician may not feel that this has any clinical meaning for the patient in terms of his QoL or sexual function.Commercially manufactured testosterone products should be prescribed rather than compounded testosterone, when possible.Given the increasing incidence of both testosterone deficiency and prostate cancer with advancing age, it is common for the two conditions to co-exist in older men. Guideline Statement 30 The product is provided in a metered pump that supplies 5.5 mg of testosterone per actuation. An intranasal testosterone gel applied topically into the nose was approved by the FDA in 2014. The progressive hydration tablet with a matrix containing 30 mg of testosterone is placed in position on the gum above the right or left canine and is held in position for approximately 30 seconds. The most common adverse effect with patches is application site reactions, which have been historically reported in up to 60% of patients.181 Other adverse effects include pruritus, application site vesicles, and back pain.431 Compared to topical gels and solutions, the rate of transference is likely minimal. Adverse effects specific to topical preparations include application site reactions (3-16% erythema or rash), and risk of transference. And if your testosterone levels go out of whack, you’re prone to experiencing a range of uncomfortable symptoms that can adversely affect your health. Low testosterone, known medically as testosterone deficiency or male hypogonadism, is a hot topic in the health and wellness industry, and there are endless supplements that promise to boost it. Many men with low testosterone levels have no symptoms, and many men with symptoms who receive treatment and reach goal testosterone levels have no improvement in their symptoms. Testosterone patches consist of a mixture of testosterone, penetration agents, and a gelatinous matrix separated from the skin by a microporous membrane. Although one objective of meta-analyses is to increase study power to identify significant results, this often results in an amalgamation of studies that may have different primary and secondary endpoints, thereby reducing the reliability of the outcomes. It also highlights that treating clinicians should have specific endpoints for treatment in mind, with regular monitoring of these outcomes to assure that ongoing therapy is warranted and effective. Readers should recognize that guideline statements have been generalized in an attempt to provide a clinically useful document with the understanding that certain populations and clinical scenarios will fall outside of the initial criteria upon which the studies were based. This is further complicated by laboratory methodology issues, such as time of day for the blood draws analyzed, number of levels checked, and assays used. The prevalent confusion about the diagnosis of testosterone deficiency, the inappropriate use of testosterone replacement therapy and the recent reports of potentially increased risk of serious adverse effects with the use of testosterone replacement therapy indicate an important need for guidance among health professionals in the management of testosterone deficiency. The task force recommends that the initial biochemical test be total testosterone level measured in a blood sample taken in the morning (or within three hours of waking in the case of shift workers), and that determinations of bioavailable testosterone or free testosterone be restricted to patients found to have equivocal low total testosterone levels (Box 2). This guideline is intended to address clinical questions surrounding the diagnosis of testosterone deficiency and the appropriate use of testosterone replacement therapy in the management of these patients. Visit Healthy Male for more information about male reproductive and sexual health If you have low testosterone, you can take testosterone replacement therapy. Your doctor may also want to measure your iron levels to check for haemochromatosis. Testosterone levels can vary, so if you have a low level on one blood test, a second test is needed to confirm low levels. If you think that you have any of the symptoms of low testosterone you should talk to your doctor. Although direct measurement of free testosterone has a generally good correlation with equilibrium dialysis, it is not reliable because of high CV. This is based on the concept that the free testosterone fraction is believed to be the most biologically active component. The most accurate testosterone measurements are obtained in the early morning and on more than one occasion, which is not uniform across testosterone trials. Clinicians wishing to identify laboratories meeting CDC standards are encouraged to refer to the list of sites currently meeting CDC requirements listed on the CDC Hormone Standardization Program. Testosterone deficient patients should be informed that low testosterone levels place them at risk for these major cardiovascular events and clinicians should assess all testosterone deficient patients for ASCVD risk factors, both fixed (e.g., older age, male gender) and modifiable (e.g., dyslipidemia, hypertension, diabetes, current cigarette smoking). Patients with testosterone deficiency who maintain testosterone levels in the normal range while on testosterone therapy should have their PSA levels tested, utilizing a shared decision-making approach, in accordance with the AUA's Early Detection of Prostate Cancer Guideline. Another meta-analysis of 37 studies138 found that diabetic men had significantly lower testosterone values than those who did not have diabetes; individual studies with adjusted point estimates also support this outcome.97, 133, 139 A multivariate logistic regression model from one study of 1,089 men who had total testosterone 94 Corona et al. likewise found that the prevalence of low testosterone levels (defined as total testosterone of 107 The cut-off of 300 ng/dL was chosen based on the mean total testosterone levels cited in the best available literature with a view to maximizing the potential benefit from prescribing testosterone while minimizing the risks of such treatment. It was decided that a cut-off value was critical to define testosterone deficiency and that this cut-off be based on at least two total testosterone levels drawn in an early morning fashion at the same laboratory using the same assay. Liquids and gels should be applied to clean, dry skin, and the treatment site should not be washed until the time of next application to optimize delivery. In analyzing the literature, it is imperative to determine whether or not statistically significant results are clinically meaningful. Beyond statistical significance, clinical relevance is another key factor. One important aspect of study design is the specific endpoints and objective measures used to identify outcomes. If you have fertility problems because of low testosterone levels, speak to your doctors about fertility treatments and other options. Getting diabetes or other health conditions under control and losing weight can improve testosterone levels. Your doctor can check your testosterone levels with a blood test, along with other hormones that might affect them. Some females with low testosterone levels might have loss of libido. Males with low testosterone levels can have many different symptoms. Likewise, there might be value in defining the trough level (measured prior to injection on day one) to ensure patients remains therapeutic throughout the entire cycle. While mid-cycle testing is convenient for patients, there may be value in assessing peak level (18-36 hours after injection) as the adverse events (e.g., polycythemia, hyperestrogenism) are likely at least partially related to the peak level. It restores the circulating testosterone level to the physiological range. There are many reasons that you may have low testosterone levels. Testosterone levels can vary greatly depending on your sex, age and health. PATH supports research that improves the diagnosis and treatment of hormone disorders, including a landmark 2017 study that defines the “normal” range of testosterone in young adult men. A variety of other medical conditions can cause significantly lower-than-normal testosterone levels in boys and men. TRT seems to be more effective in young men with very low testosterone levels. The testosterone therapeutic space is relatively unique. For most pharmaceutical products, the usage, dosage, and application is consistent across brands, and identification by chemical compound is sufficient to communicate to the reader when to use a given medication. The AUA has a policy that all pharmaceutical and biological agents are referred to only by their chemical compound formulation in guidelines, white papers, and best practice statements and not by their brand or generic name. Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinion with consensus achieved using a modified Delphi technique if differences of opinion emerged. Conditional Recommendations also can be supported by any evidence strength. Phone (New Patients) Low testosterone might impact sleep due to its impact on cortisol. According to recent research, memory loss can be a sign of low testosterone. If you’re feeling depressed or irritable without reason, it could be a symptom of low testosterone. Without enough testosterone, blood may not be able to enter the penis and allow it to get rigid enough for sex. Researchers suspect the reason for this is that testosterone acts as a vasodilator, allowing more blood flow into the penis, says Calvert. A meta-analysis of RCTs developed in support of this guideline indicate that there is no significant difference in MACE in men on testosterone therapy when compared to placebo. RCTs have failed to categorically define if testosterone therapy increases the incidence of MACE when compared to placebo. A discussion regarding the benefit of stopping testosterone therapy should include the possibility of a decline in PSA. PSA recurrence in men on testosterone therapy should be evaluated in the same fashion as untreated men. A low or low/normal LH level points to a secondary (central) hypothalamic-pituitary defect, (hypogonadotropic hypogonadism), while an elevated LH level indicates a primary testicular defect (hypergonadotropic hypogonadism).168 In men with hypogonadotropic hypogonadism, the yield from adjunctive tests (e.g., prolactin measurement, pituitary imaging, iron studies) is increased. LH, which is routinely measured by immunoassay, may help to establish the etiology of testosterone deficiency and can be an important factor in determining if adjunctive tests should be ordered (Appendix C - refer to the Appendix C section in the left menu). Their role in diagnosing testosterone deficiency is unclear, and they should not be used at the expense of a full patient evaluation, including laboratory testosterone measurement. Screening questionnaires are not an appropriate tool to identify candidates for testosterone therapy. Male hypogonadism is also known as low testosterone or low T because the testes (aka the testicles) produce insufficient levels of the hormone testosterone. The task force did not find compelling evidence for withholding testosterone therapy in symptomatic men who also have cardiovascular disease or localized prostate cancer. It was of considerable interest that 61% of the respondents (including a portion of those who considered themselves comfortable with the diagnosis and management of testosterone deficiency) agreed to be part of a follow-up study. Randomized controlled trials (RCTs) were sought for effectiveness questions, whereas both randomized and non-randomized studies were sought for adverse events and questions of association and risk factors. Minimal data were found regarding outcomes of frailty, risk of venous thromboembolism, hyperestrogenemia, sleep apnea, prostate biopsy, recurrence of treated prostate cancer, and incidence of breast cancer. Of the outcomes included in the protocol of this systematic review, data were available on quality of life (QoL), sexual function, cardiovascular events, anemia, bone health, insulin resistance, cardiovascular risk factors, mood, cognitive function, body composition, and numerous adverse events. Clinicians should inform testosterone deficient patients that low testosterone is a risk factor for cardiovascular disease. The diagnosis of low testosterone should be made only after two total testosterone measurements are taken on separate occasions with both conducted in an early morning fashion. The AUA and the Testosterone Panel were committed to creating a Guideline that ensures that men in need of testosterone therapy are treated effectively and safely. It is the opinion of the Panel that testosterone therapy, with close monitoring to ensure appropriate dosing and safety surveillance, may be considered in these patients after a three to six month waiting period. The currently available literature does not provide enough evidence to offer clear guidance on the use of testosterone therapy in men with existing, stable atherosclerotic CVD and/or a remote history of a myocardial infarction or a cerebrovascular accident. A larger study that examined the contraceptive efficacy of testosterone-induced azoospermia in men was conducted by the WHO Task Force on Methods for the Regulation of Male Fertility.385 A total of 271 healthy, fertile men across 7 countries were given 200 mg IM testosterone enanthate every week for 12 months. Exogenous testosterone therapy has been shown to interrupt normal spermatogenesis and can put patients in severely oligospermic or azoospermic states and should not be used in men trying to conceive. At the end of the year-long treatment period, two men from the treatment arm had a definite myocardial infarction, and none were recorded in the placebo arm. Complex statistical analysis using a methodology known a stabilized inverse propensity treatment weighting was utilized to adjust for 50 potentially confounding variables. Two of the trials and one meta-analysis pointed to an increased risk of cardiovascular events,363, 364, 366 two revealed no cardiovascular risk,233, 367 and one was neutral with respect to risk.373 The Corona meta-analysis,372 which showed that there was no increased risk of cardiovascular events, was not officially reviewed but was taken into consideration in the final analysis. SQ testosterone pellets were initially developed and FDA approved in 1972 and were reformulated in the USA in 2008. An exception can be made if patients do not have symptoms but have documented BMD loss. The first testosterone measurement should be obtained two to four weeks after initial implant to determine if the number of inserted pellets needs to be increased or decreased to achieve the appropriate therapeutic level. Patients on short-acting IM or short-acting SQ pellets (testosterone cypionate or enanthate) should have their testosterone measured after several cycles such that testosterone level equilibration has been achieved. Healthy older males may have lower testosterone levels due to the ageing process itself. Low testosterone levels can lead to a variety of symptoms — like fatigue, depression, and a decrease in sex drive — and require proper diagnosis and management. Some men explore supplements to help with symptoms of low testosterone or maintain healthy levels of the hormone. One study found that 39 percent of men 45 and older have low testosterone, also known as testosterone deficiency (TD) or male hypogonadism. Testosterone levels increase during REM sleep, and there’s some evidence that disruptions in sleep could negatively impact a man’s testosterone levels, says hormone specialist Jim Staheli, D.O. Although to date there is no knowledge on the specific use of testosterone preparations in the younger adult cohort, it is likely that this group may also be using the formulations for symptoms and signs suggestive, but not documented of androgen deficiency. This suggests that commercially available T replacement is being used for symptoms such as decreased libido, erectile dysfunction depression, and fatigue who may in fact have other clinical conditions rather than androgen deficiency itself. While these medications are efficacious, using them for male hypogonadism treatment is considered off-label by the Food and Drug administration and carry side effects of decreased bone mineral density and libido (42). While there is evidence that T may reduce HbA1C, lower BMI, and reduce waist circumference other studies have not shown any change in HbA1C with testosterone compared to placebo (39). Formal weight loss programs have not only shown that the percentage of weight loss correlated with increased T levels, but parameters related to fertility including sperm motility and morphology also improved (38). TRT Transformations Prohormone supplements are marketed at men to treat low testosterone levels most commonly dehydroepiandrosterone (DHEA) Without a hormone promoting muscle development, men with low testosterone levels experience a reduction in muscle mass. Reduced sex drive is mostly observed as men age because of the gradual decline in the circulating testosterone levels. Signs of low testosterone levels appear when there are a drop below-normal testosterone levels leading to conditions like hypogonadism or infertility. As age increases in men, testosterone levels decrease. The actual prevalence of hypogonadism has been estimated to be 39% in men aged 45 years or older presenting to primary care offices in the United States. Your doctor will be able to test for testosterone imbalances and then help you correct them to mitigate these signs and symptoms. You may also not be a good candidate if you've had prostate cancer or a history of heart disease, as these can increase your risk. Low testosterone can have many causes, and identifying the right one helps guide the best treatment plan. Still, it's important to address symptoms early to help protect your long-term health and catch any underlying conditions. Other meta-analyses that have included observational studies with less stringent inclusion criteria have demonstrated variable improvements in fasting glucose, insulin resistance, and HbA1c levels.138, 325, 326 The rate of remission was also higher in a statistically significant manner among dysthymic men receiving testosterone therapy (53%) compared to placebo (19%).317, 318 Furthermore, additional testing, such as parathyroid hormone, calcium, and vitamin D levels, may be required. One trial with three years of follow-up showed near linear, time-dependent improvements in BMD.202 These findings are similar to other prospective, controlled data, which report an estimated 5% per year increase in BMD in men on testosterone therapy.309 Declining bone density may necessitate additional medical intervention, such as weight bearing exercise, calcium, vitamin D, or bisphosphonate medications. At the present time, there are insufficient data available to predict which men with ED are most likely to respond to testosterone therapy. This is called acquired hypogonadism. A trait passed through families, also called inherited, can cause either type of hypogonadism. Fluid from the seminal vesicles and prostate gland combine with sperm to make semen. An estimated 35 percent of men older than 45 and an estimated 30 to 50 percent of men with obesity or type 2 diabetes have hypogonadism, according to the Endocrine Society. The market is flooded with testosterone-boosting supplements, but consumers should know that some may not be effective. Estrogen also raises the odds of endometrial cancer (cancer of the uterine lining), but adding progestin lowers this risk. Women may be prescribed hormone replacement in the form of estrogen, progestin (another hormone), or estrogen with progestin. Some authorities have advocated that free testosterone should be the primary measure used to define testosterone deficiency. The Panel recommends that clinicians use the same laboratory with the same method/instrumentation for serial total testosterone measurement. There is a great deal of variability across studies with respect to the forms of testosterone measured (total versus free), the assays utilized to measure testosterone, the time of day when the sample is obtained, and the number of testosterone measurements taken. As an example, a total testosterone value of 250 ng/dL may be considered low based on the current guideline but be marked within the normal range by the laboratory. Due to the challenges in testosterone methodology, there is considerable variability in testosterone reference ranges.13 The specific reference ranges used to diagnose testosterone deficiency are discussed in more depth later in this document. The physician is encouraged to carefully follow all available prescribing information about indications, contraindications, precautions and warnings.The product is provided in a metered pump that supplies 5.5 mg of testosterone per actuation.Radiation to the brain that exposes the pituitary gland can also result in pituitary dysfunction and low testosterone.Evidence strength refers to the body of evidence available for a particular question and includes not only individual study quality but consideration of study design, consistency of findings across studies, adequacy of sample sizes, and generalizability of samples, settings, and treatments for the purposes of the guideline.In 2014, the FDA added a warning to testosterone product labeling after reviewing five observational studies and two meta-analyses of RCTs that examined the effects of testosterone therapy on MACE.LH, which is routinely measured by immunoassay, may help to establish the etiology of testosterone deficiency and can be an important factor in determining if adjunctive tests should be ordered (Appendix C - refer to the Appendix C section in the left menu).This leads to the development of a range of signs and symptoms in men.Men who are experiencing low testosterone can receive expert treatment at Tampa General Hospital.According to recent statistics, high testosterone affects about 5% of men, with the highest prevalence among men in their 40s and 50s. For many men, low testosterone treatment involves testosterone replacement therapy (TRT). A urologist can accurately diagnose low testosterone by measuring the level of testosterone in your blood, typically done in the morning when levels are highest. However, when levels drop too low, it can lead to a condition called hypogonadism, which significantly impacts quality of life. Testosterone therapy can also cause hormonal changes that lower the amount of testosterone that the testes are making, decreasing sperm production and fertility, according to the American Society for Reproductive Medicine. With worsening Leydig cell function, there is a reduction in the feedback mechanism resulting in elevation of LH levels (hypergonadotropic hypogonadism). Pituitary dysfunction may be a significant cause of testosterone deficiency. Testosterone deficiency is prevalent in men presenting for an infertility evaluation.159 The testes contain germ cells that produce spermatozoa and Leydig cells that produce testosterone; any pathology of the testes can result in infertility and testosterone deficiency, conditions that frequently co-exist. Gynecomastia is a benign enlargement of the male breast tissue that can occur at times of male androgen/estrogen change (alteration in testosterone/estradiol E2 ratio), infancy, adolescence, or old age, and may be a sign of low serum testosterone. Low testosterone in women can be difficult to diagnose because a direct correlation between symptoms and low T has not been established, and there is a lack of accurate tests for androgen levels and valid reference ranges for women. Low testosterone in men — male hypogonadism — can occur at any age, as a result of problems affecting the testicles or the pituitary gland. Generally, people with testosterone levels above 916 ng/dL are considered to have high testosterone. Treatment with testosterone therapy may help reduce symptoms. Male hypogonadism means the testicles don't make enough of the male sex hormone testosterone. Common symptoms of low testosterone in men include flagging energy levels, low libido, and weight gain. Here’s how to avoid symptoms of low testosterone or improve your levels.21 Getting treated for any underlying conditions may also help testosterone levels. As such, identifying modifiable risk factors that may lead to hypogonadism should be an early step in patient evaluation as correction of many of the aforementioned conditions may mitigate the need for TRT. When designing a treatment plan for TRT in young adults, clinicians must understand that most exogenous T therapy will suppress spermatogenesis and decrease fertility potential (36, 37). Along with the aforementioned etiologies of hypogonadism, this highlights the importance of a comprehensive patient history in order to elucidate underlying factors that may contribute to hypogonadism in younger patients. A survey of 120 patients who were treated for infertility at the University of Illinois-Chicago found that the incidence of testosterone deficiency was 45% in men with non-obstructive azoospermia, 42.9% in men with oligospermia, and 16.7% in men with obstructive azoospermia.159 BMD increased in patients treated with testosterone therapy leading the authors to conclude that younger testosterone deficient men may benefit from having routine DEXA scans performed, particularly those with concomitant low E2 and low BMI.89 A systematic review found that varicocele ligation results in significant improvement in testosterone levels in some men, with a mean improvement of approximately 100 ng/dL. Total testosterone absence of signs and/or symptoms increases the likelihood of making a false diagnosis and reduces the potential benefit of testosterone therapy. Acute illnesses should be considered when measuring testosterone levels, the presence of which can affect the accuracy of the test and lead to artificially decreased testosterone measurements. There is also increasing evidence that anti-Mullerian and inhibin B levels can improve the sensitivity and result in earlier diagnosis which ultimately allows for treatment to start at a younger age (10). Outside of modifying identifiable risk factors for hypogonadism, pharmacologic testosterone therapy can also lead to therapeutic dilemmas in young men who desire paternity. In older males, physiologic changes of the aging testis, account for the majority of decreased testosterone levels in this population. If you have low testosterone levels, you are at a higher risk of developing osteoporosis and breaking your bones. Additionally, many men claim that their brain fog lifts when they start testosterone replacement therapy, says Calvert. A 2021 study found that men with higher concentrations of testosterone scored better on measures of verbal memory and mental processing speed compared to men with lower concentrations.7 Some physical changes to your body happen naturally with age, but some may be directly related to low testosterone. Other symptoms of low testosterone can chip away at your sex drive, too, like low energy or weight gain. One of the most common and noticeable symptoms of low testosterone is a low sex drive. Read on to learn about some of the lesser-known warning signs of low testosterone. The complications of untreated hypogonadism differ depending on whether it starts in the womb, at puberty or in adulthood. At times, primary and secondary hypogonadism occur together. Transdermal Agents - Patches Similarly, in the event patients have unexplained anemia that improves on testosterone therapy, continuation can be considered even in the absence of other symptom improvement. In this clinical scenario, an argument can be made to continue testosterone therapy. As such, even if consistent testosterone levels could be achieved, providers issuing prescriptions for compounded testosterone need to consider performing additional monitoring and dose adjustments to ensure appropriate therapeutic levels. It is approved in some countries for treatment of testosterone deficiency but is not currently approved in the US. It's also commonly known as testosterone deficiency syndrome (TDS), Low T, or male hypogonadism.Therefore, except in older men, a morning (7 to 11 AM) serum total testosterone should be checked initially, if testing is necessary.Ignoring symptoms of testosterone problems is a surefire way of worsening your condition over time.Though testosterone levels naturally decrease with age, certain lifestyle habits can speed up that process.Well-established reference ranges constitute the essential basis for identifying whether the circulating levels of a particular analyte, testosterone in this case, are normal or low.Fluid from the seminal vesicles and prostate gland combine with sperm to make semen.Body fat contains an enzyme called aromatase that converts testosterone into estrogen, causing hormonal imbalance. Testosterone is the predominant androgen in males and is involved in a multitude of physiological and biochemical processes throughout the body. Early morning samples from each subject's most recent and previous 3 visits as well as those from 10, 15, 20, 25, and 30 years prior were analyzed (3,565 samples total with a mean of 4 samples per patient). A detailed profile of the therapeutic agents discussed in this guideline can be found in Appendix B (in the Appendix B section in the left menu). To merely refer to injectable or gel testosterone formulations without differentiation does not impart complete and accurate information to the reader. For example, there are several testosterone gels available in 1%, 1.62%, and 2% formulations, each marketed under a different brand or generic name. He blogs about men’s health topics, including steroids, testosterone, and male infertility, on the Turek Clinic’s website. PATH formed in 2010 to help the clinical, medical, and public health communities improve patient care through more accurate and reliable hormone tests. Male menopause; Andropause; Testosterone deficiency; Low-T; Androgen deficiency of the aging male; Late-onset hypogonadism At this time, it is unclear whether TRT increases the risk of prostate cancer or symptoms of benign prostatic hyperplasia. They can evaluate your symptoms, order blood tests and refer you to a specialist if necessary. For initial testing and recommendations, talk with a primary care doctor who specializes in men’s health. For some men, medicines like clomiphene citrate or supplemental human chorionic gonadotropin can increase testosterone production without affecting fertility. Although the committee reviewing the evidence concluded that there was not enough data to definitively state that testosterone therapy posed a significant cardiovascular risk, the FDA nonetheless required testosterone product manufacturers to add information to the labeling about a possible increased risk of myocardial infarction and cerebrovascular accidents in patients using testosterone therapy. Mean peak total testosterone levels are dose-dependent, with a mean of 746, 866, and 913 ng/dL noted with 8, 10, and 12 pellets administered (not BMI adjusted).446 The duration of effect is similar, however, and is relatively independent of dosing. Men with total testosterone level 315 ng/dL declined from 100% at 4 weeks to 86%, 75%, and 14% by 12, 20, and 24 weeks, respectively.Mean peak total testosterone levels are dose-dependent, with a mean of 746, 866, and 913 ng/dL noted with 8, 10, and 12 pellets administered (not BMI adjusted).446 The duration of effect is similar, however, and is relatively independent of dosing. One small 2016 study found that men with low testosterone between the ages of 21 to 41 were more likely to be diagnosed with depression than the control group.5 Specific areas of interest include vasectomy and vasectomy reversal, Peyronie’s disease, testosterone management, and male infertility. But some symptoms of low testosterone may be subtle, and many men don’t realize their hormones could be to blame. If you are experiencing any of these symptoms, it’s time to take action. A simple blood test can provide clear answers and open the door to effective treatment. This therapy comes in various forms, including gels, injections, patches, and pellets. The invisible symptoms of low T are often the most challenging, affecting your mood and cognitive function. The effects of low testosterone extend beyond the bedroom, often manifesting in noticeable physical changes that can be frustrating and concerning. This guide will walk you through the ten most common signs of low testosterone, covering the physical, sexual, and emotional changes you shouldn’t ignore. Depending on the cause and age when low T first appears, symptoms can differ.Furthermore, the concept of testosterone 'crash' is well recognized by clinicians, with large differences between peak and trough levels potentially leading patients to become symptomatic towards the end of the cycle despite having therapeutic trough testosterone levels.Testosterone levels are most often highest in the morning.In men years of age, biennial PSA testing should be considered.Given these pharmacologic and mechanistic differences, combinations of these alternative therapies might, in some instances, be clinically appropriate.The sequela of osteoporosis becomes evident only when the hypogonadism has been present for long periods.12 None of these findings, alone or in combination, are sufficient to make a diagnosis of testosterone deficiency syndrome.Along with the aforementioned etiologies of hypogonadism, this highlights the importance of a comprehensive patient history in order to elucidate underlying factors that may contribute to hypogonadism in younger patients. Patients with obesity, poorly controlled diabetes, or opioid usage should be counseled on weight loss, diet, exercise, and drug abuse before starting testosterone replacement therapy (TRT). According to the European Male Aging Study at least three clinical sexual symptoms should be present in conjunction with the laboratory abnormal values to confirm the diagnosis of androgen deficiency (8). This threshold along with various others defining low total T set from 250 to 300 ng/dl by other societies such as the American Urological Association have been established regardless of age following many large-scale population studies (35). The clinical symptoms of hypogonadism are non-specific, making diagnosis challenging in adolescents and young men. Testosterone deficient patients with low or low/normal LH levels can be considered candidates for SERM use as a treatment for testosterone deficiency, particularly those wishing to preserve their fertility.170 However, an LH level below which SERM response is optimized is not firmly established. A retrospective review of 399 men (mean age 37 years) with a mean total testosterone of 308 ng/dL found that 35% of patients had BMD at osteopenic levels and 3% had osteoporosis. Specifically, the odds ratio for developing ED in men with total testosterone 6 used a single question to define ED and also showed an increase in ED risk as total testosterone levels decreased. In a small study of young men with acute respiratory infections, mean total testosterone levels declined by 10%, with some cohorts experiencing reductions of up to 30%.25 Patients should be monitored for 30 minutes in a healthcare setting after injection to monitor for POME or anaphylactic-type symptoms. These data are notable as they demonstrate far less variability between peak and trough levels compared to shorter-acting preparations.441, 442 Results after the third injection demonstrated median peak and trough T levels of 813 ng/dL and 317 ng/dL, respectively, with overall median values of 476 ng/dL during the 10-week period. The potential benefits and harms that can be expected from testosterone supplementation are listed in Table 1.17,18 Lack of or an inadequate clinical response to testosterone treatment should call for changes in the form of delivery, the dose or the frequency of administration. An algorithm outlining an approach to the diagnosis of testosterone deficiency is available in Figure 1. In the diagnosis of testosterone deficiency, the physical examination bears similar shortcomings to those of patient history, mainly because of lack of specificity. Testosterone levels are controlled by a feedback loop between your brain, your pituitary gland and your testes. In females, testosterone is needed for bone and muscle strength and sex drive. In males, most testosterone is made by the testes. Males and females both naturally produce testosterone, though males produce far more than females. As described above, diet, stress management, and several other nonmedical approaches may be effective in staving off low testosterone issues. The controversy surrounding prostate cancer and testosterone stems from the work of Dr. Charles Huggins who discovered that treating metastatic prostate cancer patients with ADT resulted in cancer remission,341 suggesting that the presence of testosterone would lead to an increased likelihood of prostate cancer development. Using stricter criteria for inclusion (only RCTs), Cai et al.324 demonstrated minor improvements in triglycerides (-13.5 mg/dL) among testosterone treated men in 4 RCTs of men with testosterone deficiency. Several meta-analyses have evaluated the impact of testosterone therapy on lipid profiles. However, when patients were requested to assess their global impression of change regarding energy level, men receiving testosterone were significantly more likely to rate changes as a little or much better compared to placebo (approximately 15% more in testosterone cohort). Compared to placebo, no significant changes were noted with testosterone therapy, including when the data were evaluated as a continuous or dichotomous (≥4 point change) variable. For example, PSA levels of 1.5 ng/mL, 2.3 ng/mL, and 3.3 ng/mL over 3 years do not meet the first indication for urology referral (more than 1.4 ng/mL over a year's time) but show an average PSA velocity of 0.9 ng/mL and require referral based on that criterion (11). Patients receiving the intramuscular testosterone enanthate or cypionate should have levels checked midway between injections, and levels should be checked 3 to 12 hours after application in the case of transdermal patches (11, 13). Testosterone levels should be monitored 3 to 6 months after initiation of treatment. The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Finally, a randomized trial of 76 men (mean age 50.6 years), who had at least 1 ejaculatory dysfunction symptom and at least 2 testosterone tests 182 An evaluation for a prolactinoma in such patients is imperative because these benign tumors can be effectively managed using medications, such as bromocriptine or carbergoline. Depending upon the radiation dose, delivery modality, and underlying tumor type, LH deficiency rates in patients whose pituitary gland has been exposed to radiation is 10-96%.160 Men with total testosterone level 315 ng/dL declined from 100% at 4 weeks to 86%, 75%, and 14% by 12, 20, and 24 weeks, respectively. Although the absolute risks of POME and anaphylaxis require ongoing study, data from 342 patients undergoing 3,022 injections (1,000 mg in 4 mL) over a period of 3.5 years demonstrated that POME occurred after 1.9% of injections (12% of patients experienced at least one POME), with coughing episodes lasting 1-10 minutes in duration.443 All episodes were managed conservatively in the clinic, with no supplemental oxygen required. Further individualization may be considered based on trough testosterone levels at the end of a 10-week injection cycle. Historically, testosterone levels have been measured mid-cycle (day three to four); however, such a measurement protocol misses the ability to define peak and trough levels. It is therefore important to recommend weight loss either prior to or concomitant with TRT in obese patients. Androgen rise has been found to be greater in those patients who lose more weight (14, 15). During the initial workup, if a clear treatable condition that explains androgen deficiency is diagnosed, it should be addressed first (11, 14). Given the clinical and commercial testosterone landscape, the American Urological Association (AUA) identified a need to produce an evidence-based document that informs clinicians on the proper assessment and management of patients with testosterone deficiency. The care of testosterone deficient patients should focus on accurate assessment of testosterone levels, symptoms and signs as well as proper on-treatment monitoring to ensure therapeutic testosterone levels are reached and symptoms are ameliorated. Testosterone replacement can raise testosterone levels and help ease the symptoms of male hypogonadism. The Massachusetts Male Aging Study (10), an observational cohort study conducted on healthy men aged 40 to 70 years from the Boston area, estimated that the prevalence of androgen deficiency (total testosterone “The process of getting an erection is complex both physiologically and psychologically, and many men notice decreased spontaneous erections as the first sign of low testosterone,” says Calvert.2 Trouble achieving and keeping an erection can also be a sign of low testosterone. The experienced team at St Pete Urology specializes in diagnosing and managing low testosterone. Six patients experienced biochemical recurrence, all of whom had intermediate- or high-risk prostate cancer.A meta-analysis of RCTs developed in support of this guideline indicate that there is no significant difference in MACE in men on testosterone therapy when compared to placebo.The purpose of this article is to review the data on LOH, also known as low T, and present the most recent evidence and recommendations regarding the approach to the patient from our case scenario.If you have a condition such as diabetes and you find your nerve pain and numbness getting worse, talk with your doctor about the possibility that you may also have low testosterone.Men who have a history of chronic corticosteroid use have been shown to be at risk for low testosterone levels.The conventional belief that testosterone replacement therapy is contraindicated in the presence of advanced prostate cancer is supported by robust evidence,25 thus meriting a strong recommendation against its use (Box 2).Men were eligible for inclusion in the study if they had testosterone in the normal range, an unremarkable reproductive history and physical exam, and 2 semen samples with a sperm concentration of ≥20 million/mL.Aside from TRT and medicines, treatments for low testosterone depend on the cause. In contrast, other studies have found increased cardiovascular mortality in patients with testosterone deficiency (19). If testosterone is confirmed to be low, it is recommended to categorize the hypogonadism as primary or secondary by checking levels of luteinizing hormone and follicle-stimulating hormone. There is some evidence that a glucose load can significantly decrease testosterone levels for a short time, so conducting this test in the fasting state may result in improved accuracy (13). This syndromic approach involving clinical and biochemical criteria allows physicians to identify patients who are symptomatic from androgen deficiency and separate them from those with isolated biochemical hypogonadism and nonspecific symptoms from aging. Measuring testosterone levels became easier in the 1970s, and it wasn't long before levels were being checked in men across all age groups. In very rare cases, a child who is genetically male or female may be born with genitals of the opposite sex, or sexual organs that are neither clearly male nor clearly female (ambiguous genitals), or underdeveloped genitals. Other research has shown that exposure to pesticides, radiation, air pollution, heavy metals, or other endocrine-disrupting chemicals may create oxidative stress, which may lead to reproductive disorders that begin in the fetal stage. Primary hypogonadism Primary hypogonadism doesn’t involve the hypothalamus or pituitary but can be traced directly to abnormalities in the testes or ovaries. Men with low Testosterone experience extreme fatigue and a decrease in energy levels despite getting plenty of sleep or rest. Having male hypogonadism can affect how you see yourself. A pituitary tumor may need treatment with surgery, medicine, radiation or replacement of other hormones. If patients achieve target testosterone levels, but do not feel that they have sufficient improvement in their symptoms, clinicians should question whether testosterone deficiency is the etiology of their symptoms. Liu et al. conducted a double-blind, placebo controlled, randomized trial assessing response to hCG therapy in older men (mean age 67 years) with androgen deficiency.399 The authors found a 150% increase in total testosterone level, which they concluded demonstrates that older males retain "testicular responsiveness" to gonadotropin therapy. Prostate cancer patients on testosterone therapy should have their PSA levels monitored on the same schedule as men without testosterone deficiency; however, clinicians may choose to increase the frequency of testing. At the end of the study, serum testosterone levels rose in those men receiving testosterone therapy; however, no rise in testosterone levels were seen within the prostate tissue itself. The main purpose of testosterone therapy is to return patients to normal physiological testosterone levels and provide relief of symptoms or signs. In the event that a patient may have hypogonadotropic hypogonadism, adjunctive tests should be ordered. Hypogonadotropic hypogonadism can result from a number of conditions, including congenital abnormalities (e.g., Kallman syndrome), as well as pituitary or suprasellar tumors, pituitary infiltrative disorders (e.g., hemochromatosis, tuberculosis, sarcoidosis, histiocytosis), medications (i.e., chronic narcotic exposure), hyperprolactinemia, prior head trauma, pituitary apoplexy, and severe chronic illness. However, the literature at this time fails to define the LH level below which such adjunctive testing is warranted. The validated instruments include ADAM, Quantitative ADAM, Aging Male Survey (AMS), MMAS, and the ANDROTEST.10, 166, 167 Specificities and sensitivities vary greatly amongst these tests making them ill-suited for screening or for use as a surrogate for testosterone laboratory testing. In the fetal stage, a lack of hormones can impede the growth of the sexual organs. Causes of secondary hypogonadism include the aging process, pituitary gland disorders (such as a pituitary tumor or tumor treatment), certain inflammatory diseases, HIV/AIDS, and some medications (such as certain opiates). Secondary hypogonadism This form of hypogonadism results from abnormalities in the pituitary gland or a hormone-producing area of the brain called the hypothalamus gland. In adolescents, hypogonadism can delay or prevent puberty and the sexual development that typically occurs during that stage of life. There are many possible causes of hypogonadism, including genetics, environmental influences, and certain health issues. We process personal information and consumer health data to provide you with our products and services and maintain essential website functionality. Hone-affiliated medical practices are independently owned and operated by licensed physicians who provide services using the Hone telehealth platform. Endocrine disrupting chemicals that lurk in your home can kill testosterone. Research-backed tools, tactics, and techniques to maximize your health, delivered to your inbox every Monday. Hypogonadism and high testosterone are conditions caused by an imbalance of testosterone. By incorporating these natural strategies into your daily routine, you can keep your body healthy and agile well into your 80s. Here are a few signs to look out for if you suspect you have high testosterone. However, hypogonadal men with successfully treated prostate cancer may be candidates for testosterone supplementation. Conversely, concerns about testosterone supplementation promoting the development and growth of prostate cancer and benign hyperplasia have long been based on extrapolations more so than on real proof or verification. The choice of product for testosterone replacement therapy should be a topic of discussion between the physician, the patient, and the patient’s caregiver, if appropriate. Monitoring is an integral and mandatory part of the management of hypogonadism. Notable exceptions include secondary hypogonadism amenable to therapy aimed at improving pituitary function, metabolic alterations that may respond to other measures (see the section on Alternative and Complimentary Treatment in Appendix 1) and potential contraindications. These agents share the common overall treatment effect of increasing intrinsic production of testosterone, but there are substantial differences in pharmacologic characteristics and mechanisms of action between them. It is possible that exercise programs coupled with diet may have a greater likelihood of success in achieving increases in total testosterone over calorie-restricted diets alone. Across all studies, men had a mean baseline testosterone of 323 ng/dL, mean age of 59.9 years, and were followed for an average 34 weeks, during which time they were administered either a placebo or one of several testosterone modalities. Studies reporting optimal testosterone levels yielded a mean 2.2 kg increase in lean body mass compared to a non-significant 0.8 kg increase when suboptimal levels of testosterone were achieved.Male hypogonadism is a condition in which the body doesn't make enough of the hormone testosterone or enough sperm or both.For further information on the testosterone therapy and the risk of MACE, please see Appendix D (in the Appendix D section in the left menu).Sometimes your body can't make enough testosterone.Only 1% of male breast enlargement is caused by malignancy,76 however with any enlargement of the male breast, the possibility of carcinoma should be considered.A variety of other medical conditions can cause significantly lower-than-normal testosterone levels in boys and men.In females, testosterone is needed for bone and muscle strength and sex drive. Related Conditions and Causes of Low Testosterone If there is an underlying cause for your low testosterone, it should be treated. FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services. They may then refer you to an endocrinologist — a doctor who specialises in hormones. Use the BMI Calculator to find out if your weight and waist size are in a healthy range. Sometimes your body can't make enough testosterone. The complications that can arise if low testosterone isn’t treated depend on when the condition develops. Nonspecific signs and symptoms such as fatigue, sleep problems, and low mood can also be caused by other factors such as medication side effects, depression, and excessive alcohol use. Your initial consultation and first treatment are COMPLETELY FREE. That said, you can manage both conditions with a comprehensive care solution with your doctor and by adopting positive lifestyle changes. However, their symptoms and characteristics manifest in different ways. We are a government-funded service, providing quality, approved health information and advice Low testosterone is when the body can't make enough testosterone to work. Its production is stimulated and controlled by luteinising hormone (LH), which is m Learn more here about the development and quality assurance of healthdirect content. Pathology Tests Explained also has more information on blood tests, including testosterone tests. In men aged years were 20-25% lower than measurements takes at 8a.m., while men aged 70 years experienced only a 10% decline between the two time points.23Intra-individual Testosterone Variability. Total testosterone values obtained at 4p.m. If a patient's first test is At this time, there is no definitive evidence indicating what the optimal time interval should be between the two separate tests. “Study after study indicates that decreased libido is the symptom that is most indicative of testosterone deficiency,” says Calvert. “A lot of guys walk into clinics running on fumes when it comes to their testosterone levels,” says urologist Joshua Calvert, M.D., a physician who works with Hone Health. TRT is designed to restore your hormone levels to a normal range, which can help alleviate symptoms and improve your overall well-being. Female hypogonadism in premenopausal age groups (younger than 45) occurs in an estimated 1 percent of the population, with an estimated 5 percent experiencing early menopause, according to a report in the October 2019 Frontiers in Endocrinology. These same habits can help women maintain healthy levels of estrogen as well, although health authorities warn that excessive exercise can deplete the body of estrogen. Dr. James Staheli, D.O., is the Medical Director for Broad Health and a family medicine doctor in Atlanta, Georgia who specializes in hormone treatment for men. Here’s a rundown of some of the biggest symptoms of low testosterone in men, so that if you’re experiencing them, you can get help. Fortunately, once they’re diagnosed with low testosterone, the symptoms are treatable. If you’re wondering whether there might be a connection between your symptoms and low testosterone, ask for a testosterone blood test. Researchers are only now beginning to explore the many ways that low testosterone can affect your health. “This damage could be from diabetes, chemotherapy, physical injury, and chronic nerve pain.” “Testosterone and its derivatives, such as DHT (dihydrotestosterone), have been demonstrated to repair damage to nerves in the peripheral nervous system, which are not part of the brain or spinal cord,” Dr. Butcher explains. Despite the methodological limitations, individual studies have shown a link between low testosterone levels and ED. A challenge in making the diagnosis of testosterone deficiency is that many of the symptoms reported by patients are non-specific and might be related to conditions other than low testosterone. Likewise, while some literature suggests that food ingestion might affect testosterone levels, the evidence is particularly weak, and the Panel does not recommend that clinicians insist on fasting prior to testing. A disadvantage of the injections is the fluctuation in serum testosterone concentration that can cause fluctuating libido, energy level, and mood. For this reason, all men should be assessed for risk of breast and prostate cancer prior to treatment. Debate also surrounds to what extent metastatic prostate cancer and breast cancer may be stimulated during testosterone treatment. Further studies are needed to determine the exact role of testosterone and TRT in cardiovascular risk. The purpose of this article is to review the data on LOH, also known as low T, and present the most recent evidence and recommendations regarding the approach to the patient from our case scenario. As a result, primary care physicians are seeing more patients like the one described above. A 56-year-old overweight man with symptoms of low energy, daytime sleepiness, and decreased libido happens to be watching a golf tournament on TV from his favorite recliner and suddenly a commercial appears.