The topic of testosterone supplementation has captured the attention of men seeking to optimize their health and vitality as they age. There’s been a proliferation of online as well as brick-and-mortar clinics offering testosterone-focused evaluations and treatment. However, given the hormone’s complex role in men’s health and history of misuse (for example, among bodybuilders), we must approach the question of testosterone therapy with knowledge and caution.
The Role of Testosterone in Aging and Health
Testosterone is often viewed as a “male hormone,” yet its effects reach far beyond masculinity. Produced mostly in the testes, testosterone is essential for reproductive health, muscle strength, bone density, mood stability and cognitive function. While testosterone levels naturally decline by approximately 1% per year after age 30 or so, the implications of this decline—and what levels are optimal for health at a given age—remain debated. Some experts argue that testosterone replacement therapy (TRT) can alleviate age-related symptoms, while others see reduced testosterone as a normal aspect of aging.
Women also make testosterone—albeit at much lower levels than men—and there’s been a lot of interest in whether women might also benefit from testosterone therapy. While this use is not approved by the Food and Drug Administration (FDA), several clinical trials have shown improved libido and overall sexual satisfaction in postmenopausal women with hypoactive sexual desire disorder (HSDD) treated with testosterone. However, the risks, if used in doses too high, include possible side effects such as acne, male-pattern hair growth, voice deepening, and lipid changes, as well as uncertain long-term impacts on cardiovascular health and breast cancer risk.
Another use for testosterone is to produce physical male sex characteristics in female-to-male transgender patients but this discussion is beyond the scope of this article.
Diagnosis: Is Low Testosterone the Cause?
Men with a normal testosterone level are generally not recommended to supplement. Therefore, the therapeutic approach starts with identifying a low testosterone level. Symptoms of low testosterone include decreased libido, fewer spontaneous erections, infertility, decreased muscle mass, fatigue, swollen or tender breasts, and depression. Of course, these symptoms could be due to causes other than a low testosterone. Most men who think they might have a low testosterone level in fact do not.
A low testosterone level, also known as hypogonadism, is diagnosed with a blood test. While there’s a “normal range” (generally 300-1,000 nanograms per deciliter for men), what’s “normal” can vary by age. Some experts advocate using age-based ranges that account for natural declines, while others believe any noticeable reduction in quality of life justifies treatment. Diagnosing hypogonadism also requires distinguishing between primary and secondary forms. Primary hypogonadism relates to issues within the testes, while secondary hypogonadism arises from problems in the brain’s hypothalamus or pituitary gland. Knowledge of the root cause of low testosterone will allow for successful treatment.
Worthy of note is the complex relationship between obstructive sleep apnea and low T. Men with sleep apnea experience disturbed sleep patterns which can interfere with the body’s natural testosterone production. Conversely, low testosterone may contribute to fatigue and increased body fat, factors that can exacerbate sleep apnea. Additionally, testosterone therapy in men with untreated sleep apnea can sometimes worsen the condition by relaxing airway muscles, leading to more frequent or severe apnea episodes. This complex relationship underscores the importance of addressing both sleep apnea and low testosterone in men experiencing both conditions.
Treatment Options for Low Testosterone
Once diagnosed, men have several treatment options.
1. Nutritional Supplements
Certain nutrients, such as zinc, vitamin D, and magnesium, play essential roles in testosterone production and can be beneficial for those on the borderline. While supplements alone may not dramatically change testosterone levels, they can support overall hormonal health, especially in those with dietary deficiencies.
2. Resistance Training
Regular strength training has been shown to boost testosterone levels naturally, making it an excellent first step for those looking to address mild symptoms of low testosterone. Building muscle also helps improve energy, mood, and metabolism—benefits that are particularly valuable as men age.
3. Testosterone Replacement Therapy
For men with confirmed hypogonadism, TRT restores testosterone levels to a healthy range. TRT is typically administered through injections, patches, or gels.
4. Alternative Medications: Clomiphene and Human Chorionic Gonadotropin HCG
For men seeking alternatives to TRT—particularly those who wish to maintain fertility—other medications like Clomiphene and HCG are viable options. Clomiphene is an oral medication that stimulates the pituitary to increase luteinizing hormone, leading to higher testosterone production. HCG, often used with TRT, preserves sperm production by mimicking luteinizing hormone’s effects. These treatments can help maintain your body’s testosterone production.
Benefits of Optimized Testosterone Levels
When testosterone levels are within a healthy range, men often experience a cascade of positive effects. Mood and cognition improve, helping reduce feelings of depression or mental fog. Energy levels rise, making it easier to stay active, while muscle mass and strength are easier to maintain. Libido and sexual health often return to normal levels, and men may even experience better overall life satisfaction.
Risks Associated with TRT
TRT can cause or worsen sleep apnea, acne, breast swelling or tenderness, and fertility issues. Two important topics require further discussion.
Cardiovascular health: While large-scale studies have shown that testosterone therapy does not significantly increase the risk of heart attack or stroke in most men, it has been associated with an increased risk of atrial fibrillation (AF) and pulmonary embolism (PE). AF is an irregular heart rhythm that can lead to blood clots and strokes, while PE is a potentially life-threatening condition caused by blood clots in the lungs. The increased risk of AF and PE may stem from testosterone’s effects on red blood cell production, which can raise hematocrit levels and increase blood viscosity. This can make blood more prone to clotting.
Prostate health: TRT is contraindicated in men with prostate cancer. Historically, there was concern that TRT may increase the risk of developing prostate cancer, but this has largely been disproven. The 2015 meta-analysis by Kang and Li examined the impact of TRT on PSA levels in men treated for hypogonadism. Analyzing 15 randomized controlled trials with a total of 739 patients receiving TRT and 385 controls, the authors concluded that while TRT may cause a slight increase in PSA levels, it does not appear to elevate the risk of prostate cancer in hypogonadal men.
Monitoring on TRT
Patients on testosterone therapy should be monitored for:
1. Increased testosterone levels and clinical improvement
2. Sleep apnea
3. Lipid profile
4. Hemoglobin and hematocrit levels
5. PSA
6. Liver function. Although rare, testosterone can affect liver function, especially with oral forms of the therapy.
Is Testosterone Right for You?
Ultimately, paying attention to testosterone can be an important aspect of healthy aging. Treatment decisions require a personalized approach that considers lifestyle, medical history, and goals. If you’re experiencing symptoms of low testosterone and wondering if treatment might benefit you, come talk to us. We’ll provide safe, individualized guidance to help you achieve hormonal balance without compromising long-term health.
Dr. Kroes, Dr.Hiroshima, Dr. Judy Kim
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