Being a digger and a bloke
Hormones: Testosterone, why do men need it?
Acknowledgement:
Andrology Australia - website at www.andrologyaustralia.org
Andrology Australia 'Men's Health Matters - Androgen
Deficiency' July 2003.
Andrology Australia Newsletter Issue 8 Spring 2003-reference
(1) Bojesen A, Juul S, Gravholt Ch (2003): Prenatal and Postnatal Prevalence
of Klinefelter Syndrome : A National Registry Study . J Clin Endocrinol
Metab 88(2):622-6
Feeling tired and grumpy? Could it be hormonal?
For normal, healthy lifestyle and sexual functioning, men need to produce a regular amount of testosterone. Testosterone not only has an effect on the physical, but also emotional and mental aspects of men's health and quality of life.
Decreased energy, mood swings, irritability, poor concentration, reduced muscle strength or bone density, and a low interest in sex may be signs of low testosterone levels, a condition also know as 'androgen deficiency'.
These symptoms are very common in older men and androgen deficiency is only one of many possible causes.
Androgen is the collective name for men's sex steroids or hormones. These produce changes in body shape and sexual characteristics typical of men. The most important androgen in men is testosterone. Androgens also play a major role in sexual and reproductive function in males following puberty.
Hormones are a substance produced by different glands in the body that circulates in the bloodstream to act on organs or tissues at another site. The pituitary gland, which is linked to the base of the brain and controlled by the hypothalamus, controls the release of hormones such as 'luteinising' hormone (LH) and follicle stimulating hormone (FSH), which stimulate and maintain the function of the testes. Testosterone levels can therefore be affected by disruption to any stage of this pathway.
Diagrammatic representation of the male reproductive
system
Picture courtesy of Andrology Australia
Testosterone or androgen deficiency
Testosterone promotes secondary sexual male characteristics, such as:
- Beard and body growth
- Promoting the growth of the prostate gland
- Contributing to male sexual functioning
- Bone and muscle growth
- Stimulating cells in the testis to produce sperm.
Symptoms and signs of testosterone deficiency may include:
- Fatigue and low energy levels
- Thinning of bones or 'osteoporosis' leading to increased risk of fractures, hot flushes
- Irritability
- Depressed mood
- Reduced sex drive.
How common is androgen deficiency?
In men over forty years, testosterone levels begin to fall in a similar manner to the decline in female hormones in women. The rate of androgen decrease is approximately 3% per year, so that by the age of 65 years, 10% of men will have androgen deficiency and by the age of 70 years, this figure will have risen to over 20%'. (www.andrologyaustralia.org/testosterone/causes/older.htm - '03).
Lower testosterone levels can be caused by a combination of a reduced ability of the testes to produce testosterone, and in some men, a decrease in the amount of the pituitary luteinising hormone (LH). This decrease can occur as a result of age-related changes in the hypothalamus and/or pituitary gland.
It is normal for 50% of men between the age of fifty and seventy to have changes in their ability to obtain and maintain an erection. It is also normal for them to ejaculate less frequently between seventy and eighty years of age. Being aware of these factors and talking them over with partner is important in reducing anxiety levels in the relationship.
Treatment of androgen deficiency
Androgen deficiency is treated by testosterone replacement using tablets, implants, or patches. Untreated, testosterone deficiency is not usually life-threatening, but treatment can reverse the symptoms of androgen deficiency and is particularly important in maintaining bone mass.
CAUTION! - Testosterone may be offered as an 'instant cure' for the ageing male. Younger men may believe testosterone or other anabolic steroids can transform them into 'Superman' - lean, muscular, strong. If a small dose is good, more is better... right? - WRONG!
Testosterone may be dangerous if given without thorough medical assessment and at least two blood levels. It is possible that other medical conditions may be responsible for symptoms, rather than testosterone deficiency, and these would need to be assessed and treated in their own right.
Testosterone, or other anabolic steroids, should not be bought over the Internet, through a source at the gym/pub or any other irregular sources.
Even at recommended doses, testosterone can worsen benign and cancerous prostate disease and male breast cancer.
Taking larger doses than those generally recommended ('supra-physiological') can cause long term problems including:
- Shrinking of the testes
- Infertility
- Breast development
- Increased risk of heart disease due to changes in blood fats
- Liver disease
- Acne.
Testosterone, or other anabolic steroids, can also cause aggression, mood swings, and many other serious psychological/psychiatric problems.
Testosterone or other anabolic steroids can be abused by women too!
My doctor has recommended testosterone treatment. After all I have just read, should I be worried?
Should a second opinion be sought before starting treatment?
A second opinion is always advisable if you feel uncomfortable about any suggested course of action or if the way you are treated seems unusual. Here are some things that may indicate the need for you to consider another opinion:
- The direct sale of testosterone from the health practitioner. Testosterone treatments are not expensive and are available on the Pharmaceutical Benefits Scheme providing your test results meet the recommended criteria
- Suggested treatment with doses higher than those recommended ('supra-physiological'). While they may produce symptomatic benefits, they may not be safe
- If you feel pressured to make long-term financial commitments
- If you do not feel you are being offered ongoing review and care problems
- If treatment is suggested following a single appointment or blood test. Appropriate diagnosis requires blood testing on at least two separate occasions
- If you feel that the consultation is only focussed on testosterone levels and does not cover all aspects of general health, lifestyle and other possible illness.' (Acknowledgement: Andrology Australia - 'Men's Health Matters - Androgen Deficiency', July 2003, pp.32).
Treatment of androgen deficiency in men over forty
CAUTION! - Androgen replacement can worsen the symptoms of benign (non-cancerous) prostate disease. It is usually contraindicated in men with prostate cancer. Men with a history of prostate disease should approach testosterone replacement therapy with caution, and only consider it after full discussion with their doctor.
Testosterone replacement therapy should not be started in men with prostate or breast cancer. It is recommended for men who are over the age of forty with no signs of prostate disease.
The Endocrine Society of Australia has published guidelines that are used by the Australian Government (Pharmaceutical Benefits Scheme) for subsidising the cost of prescribing testosterone replacement.
There are a number of different forms of testosterone replacement therapy available in Australia and these include:
- Injections - into the muscle of the buttocks at intervals of 2-3 weeks. The injections can be painful and should be avoided by men who experience bleeding disorders, including those taking anti-coagulants (blood thinning medication).
- Patches - to allow the testosterone to be absorbed through the skin of the arms, shoulders, back, abdomen or buttocks. They need to be applied every night and worn all the time. About 10% of men develop a skin rash, which sometimes can improve with use of a special cream under the patch.
- Implants - of testosterone 'pellets' placed under the skin of either the abdomen or buttocks. A doctor experienced in this technique will apply a local anaesthetic and make a small cut in the skin. The implants last approximately 4-6 months. The most common problem with this form of therapy is that the pellet may work its way to the surface of the skin and eventually be pushed out.
- Oral - testosterone tablets are also available and must be taken with fluid containing fat, for example milk, to help with the absorption. The medication must be taken three times per day. This form of treatment is not frequently used unless a man is unable to tolerate others, as it does not fully replace the testosterone levels.
- Other - certain synthetic androgens are toxic to the liver and are not suitable for the treatment of androgen deficiency. There are other forms of treatment not yet available in Australia and these include gel, which is applied to the skin once a day and injections of testosterone which lasts up to ten weeks.
Risks of treatment
Side effects of treatment are uncommon, but may include mild acne, hair growth, weight gain, breast development, prostate growth, male-pattern hair loss and changes in mood (increase in aggression). Older men may experience some obstruction of urinary flow and more frequent urination or unfamiliar increases in sex drive. Men who suffer from migraines, sleep apnoea or androgen-sensitive epilepsy may experience an increase in these symptoms. There may also be an increase in red blood cells, 'polycythaemia', that can lead to problems with blood circulation. This is more likely to occur in older men, especially if they suffer from sleep apnoea.
Concerns about liver damage do NOT apply for any of the forms of androgen therapy available in Australia when legitimately prescribed and monitored by a doctor.
Side effects need to be discussed with and managed by your doctor if they occur.
Ongoing monitoring of the testosterone treatment by a General Practitioner or specialist is necessary to ensure appropriate levels are maintained and to minimise and manage any side effects. Prostate and blood tests for cholesterol may be included in this process.
Whilst there are certainly legitimate men's health clinics, a number of entrepreneurial clinics have been set up, offering treatment for erectile dysfunction at a price.
Men should be careful if clinics:
- Advertise 'instant cure'
- Do not take a careful medical history and perform physical examination as appropriate
- Do not talk about psychological causes/contributing factors of ED
- Choose injectable treatments ahead of tablets, without a clear explanation of why
- Ask for large up front payments and want you to sign a contract for several month's treatment
- Or alternatively want you to buy up front expensive injections or devices.
You should feel comfortable that your erectile dysfunction is being managed holistically in the context of your physical, psychological, and social circumstances, and that you are fully informed about treatment choices. Illegal access to steroids via the internet or other avenues (eg. at gymnasiums) for body building and other purposes is of major concern in terms of short and long-term risks to health.
Prevention of androgen deficiency
There are no known ways to prevent androgen deficiency, but a healthier lifestyle and management of other health conditions can improve testosterone production. Important factors include:
- Cigarette smoking - effects on testosterone levels is uncertain, but to assist in establishing a healthier lifestyle, 'quitting' is recommended
- Depression - Clinical depression can lower testosterone levels and medical advice should be sought to treat this condition
- Significant medical illness - can cause a drop in testosterone levels during the period of illness. Testosterone levels usually return to normal upon recovery
- Obesity - is a major and increasing health problem and is strongly associated with lower testosterone levels. Exercise and weight loss is helpful
There is no evidence that having a vasectomy causes a low testosterone level.
Where can I go for help?
- Your medical practitioner who knows your medical history is the best person to talk to in the first instance. If she/he feels unable to help there are other options available.
- Your local Family Planning Clinic will have practitioners who specialise in male health issues.
- Sexual Health Clinics have male staff who may be able to deal with your issue. They do not just treat sexually transmitted diseases.
There may be a medical centre in your area which deals specifically with men's health issues. There are also many women's health centres.
On the web
Mens Health: Andrology Australia - is an informative
site with information on the male body, prostate disease, testicular
cancer, male infertility, androgen deficiency, impotence and much more:
www.andrologyaustralia.org
Support groups and societies/professional bodies:
Endocrine Society of Australia - is a non-profit
organisation made up of scientists and clinicians who conduct research
and practice in the field of Endocrinology:
http://www.endocrinesociety..org.au
The Association of Genetic Support of Australasia (AGSA)
Phone: (02) 9211 1462
E-mail: agsa@ozemail.com.au
Website: www.agsa-geneticsupport.org.au
Klinefelter's Syndrome Support Group (KSSG)
Phone: 0407 262 398
E-mail: yatesbecks@bigpond.com