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Multiple studies have raised the question of whether or not the declining T level seen in aging men is a natural age-related process or is caused by the accumulation of multiple chronic medical illnesses that virtually all aging men experience. This definition was proposed to help clinicians identify aging men with low testosterone who could potentially benefit from hormonal replacement therapy. Aggressive marketing campaigns by pharmaceutical companies have led to increased awareness of hypogonadism among men, who may then present to the clinic requesting testing or treatment (1). 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. Channa N Jayasena received an honorarium for debating the safety of testosterone therapy at a meeting organised by the Society of Endocrinology sponsored by Besins Healthcare. First, they can order further investigations pending specialist review and, second, when NGI with potentially reversible/functional cause of low testosterone has been identified — rather than true SH — they are key to delivering long-term chronic disease management, which — based on current evidence — should not usually involve testosterone.
For many, low testosterone can be effectively managed and improved through targeted lifestyle changes and, when necessary, medical treatment. Lifestyle factors such as sleep apnea and substance abuse can contribute to decreased testosterone levels. Low testosterone can affect mental health and energy levels, often causing fatigue, irritability, mood swings and even depression. "Diagnosing low testosterone involves assessing symptoms and confirming with a blood test measuring total testosterone."
LH then travels to your gonads and stimulates the production and release of testosterone. Testosterone triggers the development of the male internal and external reproductive organs during fetal development. At around week seven in utero, the sex-related gene on the Y chromosome initiates the development of the testicles in male infants.
HIV patients with AIDS are younger and therefore, comparisons have to be carried out with appropriately age-matched controls. The HPG axis may also be affected by androgen-, or ectopic adrenocorticotropin hormone-producing tumours, leading to secondary hypogonadism (17). In a case–control study of 40 cancer survivors it was found that 90% of those on opioid treatment were hypogonadal compared with only 40% of the control group (69). Long-acting opioids such as methadone, morphine sulphate, fentanyl and oxycodone for the treatment of chronic pain often result in opioid-induced androgen deficiency (OPIAD). There is an inverse linear relationship between total testosterone and BMI, and free testosterone concentrations also decrease with increasing BMI.
Low testosterone levels are correlated with insulin resistance in both epidemiological and interventional studies, and this may be attributable to the effect of testosterone on adiposity. This is in contrast to what was found in the MMAS study where total testosterone levels were unrelated to all-cause mortality (34,35). In fact, epidemiological analyses have found that HDL levels are positively linked to testosterone levels in middle-aged men.
Certain medications and illnesses can also affect the hypothalamic–pituitary system resulting in hypogonadism (17). Primary hypogonadism is caused by testicular failure and is characterised by low serum testosterone and high LH and FSH concentrations. Apart from the vital role that it plays during puberty in stimulating the development of male secondary sexual characteristics and their maintenance thereafter, it has multiple other physiological effects. The Sertoli cells of the testes, in addition to stimulating spermatogenesis, also secrete the glycoprotein hormone inhibin, which provides negative feedback to the pituitary, inhibiting the secretion of FSH (11). Only 1–2% of testosterone circulates free in the blood; the remaining 98–99% is bound to albumin (40–50%) and to sex hormone binding globulin (SHBG) (50–60%).
It’s natural to be concerned about lower testosterone levels. Some research also suggests that high levels of prenatal testosterone levels may be linked to autism in children. A 2018 study in 60 children found that testosterone levels in the womb may also affect how your right and left brain function. Testosterone levels may start to decline after age 30 years in males and between ages 45 and 55 years in females. When most boys transition through puberty, they can credit an increase in the male sex hormone testosterone for their lower voices, hairier bodies, amplified sex drive, sperm production, and more - just in time to make them feel gangly and awkward. At UAB, men who require testosterone replacement therapy can access a full range of services through the Men’s Health Clinic, which offers various treatment options including injections, gels or creams, subcutaneous pellets, and oral medications.
A negative view of testosterone’s impact on cardiovascular disease comes from the observation that high-density lipoprotein (HDL) cholesterol levels decrease in patients on oral testosterone therapy, or when taken in supraphysiological doses by athletes (29,30). Human observational studies, however, have shown no associations between high testosterone levels and coronary artery disease, and testosterone has been shown to dilate the coronary arteries both in vitro and in vivo. Measuring testosterone levels in populations, while useful, is different from measuring hypogonadal symptoms. In this review, hypogonadism will be used as a general term to refer to any state characterised by low blood testosterone levels. A key consideration for any physician is to understand the clinical significance of low testosterone levels and how hypogonadal men are likely to benefit from testosterone replacement therapy.