Common symptoms including fatigue and irritability could be a sign of low testosterone, a hormone that’s linked to male heart health
Testosterone has become a buzzword for vitality, health, strength and sex. In fact, it’s nigh on impossible to go into any health-food store without finding tablets, supplements and other treatments claiming to boost your levels. The problem is we are now almost led to believe none of us has enough testosterone and we should all have more (even women).
But what is the truth around this hormone, and is so-called testosterone deficiency in men even a thing? Is it still considered a rare medical condition, or is it something we should all think about as we get older? What is true is that a growing body of research suggests that for men and women, it can often be key to improving midlife health and relationships.
What is testosterone?
The male sex hormone got its name in 1935 after being isolated from bull testes. In men, it is principally produced in the testicles and plays a vital role in sperm production and sex drive. However, it also affects bone and muscle mass, fat distribution and the production of red blood cells.
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Testosterone levels naturally peak in men in their early 20s and remain stable until they hit approximately the age of 30. After this age, men typically lose around 1% in testosterone production per year, but this may not have any impact on overall health. If you’re fit and healthy and born with a naturally high level of testosterone, a 1% drop may have no impact on how you feel for your entire life. However, if you are someone who is born with slightly low levels or has developed other medical problems, you might notice a drop.
What is considered low?
In the last 80 years, testosterone has been one of the most studied hormones but, despite this, the prevalence of low levels in the general population still remains controversial. Studies range from those who claim to have a single-digit level to newer research suggesting that as many as 25% of all men will have low “T”.
Nearly half of all type 2 diabetic men are thought to have low testosterone, and a large clinical trial, called the T4DM study, published in 2021, showed a link between improving low testosterone in men and an improvement in diabetic control. Prediabetes showed signs of improvement too (patients with early signs of developing the condition) in many men. And it is becoming increasingly clear the old idea that testosterone deficiency was only suffered by a handful of men is not true.
The increase in the number of men being diagnosed with low testosterone levels is probably multi-factorial. For example, we know men’s testosterone levels are declining generation after generation. We know that men will have less testosterone than their fathers, and he had less testosterone before him.
This is probably due to a combination of lifestyle factors as well as potential links with chemicals known as endocrine disruptors. However, these have yet to be proved as a major cause of male hormone problems, despite what is being peddled on social media. Other factors include lifestyle, obesity, diet, exercise and stress. And of course, the fact we are all living longer.
What are the symptoms?
In the early stages of testosterone deficiency, symptoms are hard to differentiate with normal ageing. They include tiredness, fatigue, relying on caffeinated drinks to get through the day, irritability, a loss of drive or motivation, a reduced interest in sex and sometimes mild erectile dysfunction. It’s very easy to see these symptoms could be confused with ageing.
As testosterone levels continue to drop, symptoms worsen to include loss of muscle mass, increased body fat, memory problems, anxiety, loss of libido, erectile dysfunction, development of breast tissue and changes to skin and hair. They also include disturbances in sleep such as night sweats and hot flushes.
Diagnosing low ‘T’
Luckily, it’s easy to work out if you have low testosterone, or are just getting old and grumpy. A blood test can check testosterone and free levels. It’s important to check both: testosterone is the total amount in your blood, while free testosterone is the amount you can actually use. If you’re going to ask for a blood test you should certainly get both checked.
While there is an argument to say we should not be medicalising normal life, and that testing for low testosterone when symptoms are mild might just be a waste of time and money, I would rather get tested and treated sooner than wait for severe symptoms to cause harm.
Why should we be aware of it?
One of the biggest problems the NHS faces in the next 50 years is the concept of frailty. With an ageing population, men and women are living longer but may not necessarily be living healthier lives. Longevity is about quality and not just quantity of life. Frailty refers to a “state of decreased physical and mental resilience in older adults, characterised by reduced strength, fatigue, and vulnerability to illness or injury”, and this puts an enormous pressure on the NHS in increased costs in medical and social care.
Treatment of men with low testosterone in later life can also help to reduce the risk of frailty as well as improve various other aspects of health. A trial released in 2023 was one of the largest high-quality studies. It looked at giving men who had heart disease, or who had previously had a cardiac event, testosterone replacement therapy if they had low testosterone.
The evidence from this trial showed that not only was testosterone safe to give to men who were at higher risk of heart disease, but it was also safe to give to men who had previously had a heart attack or some form of cardiac event. In addition, it also proved that testosterone replacement therapy, see below, does not increase the risk of prostate cancer and may even reduce the risk of heart disease.
Replacement therapy
Testosterone replacement therapy (TRT) was pioneered in the 1940s and it was found patients experienced an increase in muscle mass, drive, motivation and libido. Over the next few years, there were many positives and negatives associated with TRT, including questions over its link with heart disease and prostate cancer – now disproved.
The testosterone postcode lottery
In addition to generational drops in “T”, what is deemed as low testosterone is also changing, with various medical committees and governing bodies expressing different opinions, citing different research as the determinant of what should be classed as low. Even within the NHS, different regions of the country have different cut-off points for what is classed as a normal testosterone level, which can lead to a postcode lottery as to whether you are diagnosed with a deficiency or not.
Dr Jeff Foster is a GP with a special interest in men’s health and is the director of Men’s Health at Manual. Visit manual.co for more information
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