How to Find Out Causes of Low Testosterone and Get Treated

How to Find Out Causes of Low Testosterone and Get Treated

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Ok, we have to admit it – this is not intended to replace professional medical diagnosis and treatment. Use it only for an informational and educational purpose.

If you have come to read this post, you are either suffering from a low testosterone or know somebody who needs help in getting it fixed. So we are not going in depth about the hypogonadism and the symptoms. We would rather touch base on the issue and then go in-depth about the diagnosis process and the treatment plan you can seek from your health care provider.

What is Hypogonadism?

Hypogonadism or andropause or ADAMS (Androgen Deficiency in Ageing Males) is a condition where the body doesn’t have optimal testosterone. We said the body doesn’t have instead of the body couldn’t produce (as used by many other writers on the subject). It’s because at this moment of the article we are yet to identify if the body can’t produce the testosterone or it just lacks the needed stimulus to produce it. We will come to that shortly.

What happens when a man doesn’t have optimal testosterone?

Simply put, if a man lack optimal testosterone in his body, he stops feeling like a real man he used to be (given that he had optimal testosterone in the past). In other words, he lacks – sex drive, motivation, energy levels, concentration ability, endurance, muscle mass, body hair and he feels constant fatigue, depression, weakness, gets too emotional even for trivial issues, less sperm production, lesser chances of having kids as fertility gets affected. Simply put he loses the life drive. One might have all or some of the listed symptoms. Be mindful though, those similar symptoms might be caused by other health issues.

By this point, you might have come to a faint conclusion that testosterone is what makes a man a man. And you are right.

How to test your testosterone levels?

Testosterone is tested using a blood test. Depending on where you live either you can walk into a lab and ask for the test to be done or you need a doctor’s prescription for the test. Either way, you need a blood test to determine your testosterone levels.

What tests should I get done?

To identify the type of hypogonadism you are suffering from, you need to get these blood tests done.

1. Testosterone profile – Total testosterone, free testosterone, SHBG (Sex Hormone Binding Globulin)

2. Estradiol – an indicator of the estrogen levels

3. Fertility Profile – Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH) and Prolactin.

Normal ranges of these vary based on the lab where you get tested. Below is the reference range given by one of the most popular labs in India.

Testosterone – 260ng/dl to 1000ng/dl

Free Testosterone – 5ng/dL to 20ng/dL

Bio-Available Testosterone – 66ng/dL to 417ng/dL

SHBG – 10nmol/L to 57nmol/L

Estradiol (E2) – 0pg/mL to 39.8pg/mL

LH – 1.5mIU/ml to 9.3mIU/ml

FSH – 1.4mIU/ml to 18.1mIU/ml

Prolactin – 2.1ng/mL to 17.7ng/mL

What are optimal testosterone levels?

Now that is a tricky question. There is a range for normal testosterone levels but there is no recommendation for an optimal testosterone level as it could be different for each individual. What we mean is this: the normal range of testosterone is roughly 300ng/dL to 1100ng/dL, give or take some 50 points either side. Some individuals might feel absolutely normal even if their testosterone is near the lower range. Some men could develop symptoms as soon as their testosterone drops below 500ng/dl etc. So optimal testosterone level is subjective.

How to decide if I am hypogonadal?

If your testosterone is below are near the lowest range of 300ng/dL you can be diagnosed as a hypogonadal man. We suggest considering below 400ng/dL to be taken seriously for lifestyle changes to improve it.

How many types of hypogonadism are there?

This is a good question. There are two types of hypogonadism – Primary and Secondary.

Primary Hypogonadism – When your gonads are failing to produce enough testosterone despite being enough stimulus from the hypothalamus, you are said to be suffering from primary hypogonadism. Simply put your gonads (testicles) gave up and can’t produce testosterone.

Secondary Hypogonadism – Your gonads are capable of producing testosterone, but there is no sufficient stimulus from the hypothalamus. Simply put, your gonads need the signals to produce more testosterone. In this case, you are secondary hypogonadal.

If your LH, FSH, and Prolactin levels are in the optimal range and your testosterone is low then you are a primary hypogonadal man. The optimal range for LH is anywhere between 3 to 7 mIU/mL and it is the precursor for the testosterone production.

What are the treatment options for Primary Hypogonadism?

As described above, your Hypothalamus-Pituitary-Adrenal axis is working fine as suggested by the fertility tests for LH, FSH and Prolactin. Your testicles are not able to produce the optimal testosterone despite having the stimulus. In this case, it is the opinion of many urologists that Testosterone Replacement Therapy (TRT) is the best option. We also suggest that you make healthy lifestyle changes – eat nutritious food, exercise and shed extra pounds.

The drawback of this treatment is that you have to take it throughout your life and you may not be able to father a child as the testosterone you take will impact spermatogenesis. Last but not the least, discuss with your urologist who is well experienced in treating hypogonadism.

What are the treatment options for Secondary Hypogonadism?

Condition-1

If you have normal LH, FSH, and elevated Prolactin levels, then you will be prescribed Cabergeline to bring the prolactin levels to normal since elevated prolactin is known to cause hypogonadism. If you don’t see any improvement with normal LH, FSH and Prolactin levels, well you are primary hypogonadal.

Condition-2

You have low levels of LH, FSH and normal Prolactin levels.

The low levels of LH and FSH are not the sole indicators of secondary hypogonadism. You have to really examine if your gonads are capable of producing optimal testosterone when the stimulus is provided. There are two ways urologists will try to test it.

Option-1: Taking Clomiphene Citrate which tricks the hypothalamus thinking there is low estrogen in the body and hence more of LH and FSH are released. Usually, in this stimulus test, you will be asked to take 25mg to 50mg of Clomiphene Citrate every day for 3 to 4 weeks. After that time, your testosterone, LH, FSH, and Estradiol will be tested again to see if the stimulus worked.

If there is an improvement, you will be prescribed Clomiphene Citrate treatment for the next 3 to 6 months and every three months you have to check your Estradiol, Hematocrit and PSA (Prostatic Specific Antigen). Testosterone is known to increase hematocrit and it might cause other health problems if not controlled (usually drinking more fluids and vegetables will control it). If somebody already has Prostate cancer, then Clomiphene Citrate will make it even worse. Otherwise, neither testosterone nor Clomiphene Citrate is known to impact PSA levels.

If there is an issue in your Hypothalamus-Pituitary-Adrenal axis, you will not notice any change in your testosterone, LH and FSH levels. Your doctor might prescribe other tests to find out the problem. For now, you will have to go for option-2.

Option-2: Since the Clomiphene Citrate test has failed as you had an inherent issue in your HPA axis, you will be given an injection called HCG (Human Chorionic Gonadotropin). HCG is an LH analog, that means it mimics LH and your gonads think it’s the signal from HPA to produce more testosterone. An injection once every three days or one week is prescribed. After 3 to 4 weeks your tests will be repeated to see if there is any improvement in your testosterone. If the improvement is observed, you have to continue the routine. If there is no improvement even with Option-2, then you are a primary hypogonadal man (along with an inherent issue with your HPA).

Any treatment for hypogonadism consists of a routine to maintain optimal testosterone, estradiol, hematocrit, and PSA. It is not as simple as taking a pill or an injection.

Note on Estradiol

When one’s testosterone increases, it gets converted into estrogen by a process called aromatization. If most of the testosterone gets converted into estrogen, it is of no good and you develop man boobs, gets very emotional and lack energy. Also, too much estrogen harbors cancer in the body. So your urologist will put you on Anastrazole, an aromatase inhibitor to keep the estrogen in check.

We tried to elaborate the diagnosis and treatment options for hypogonadal men as much as possible. Bring back your manliness.

References:
1. Google Scholar Articles
2. https://jeffreydachmd.com/clomid-for-low-testosterone-part-one/
3. https://www.sciencedirect.com/science/article/pii/S0022534714030249
4. https://www.nature.com/articles/3900981
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508437/

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