In some ways, testosterone and Low-T have been getting a bad wrap lately. Direct-to-consumer marketing has resulted in a dramatic increase in the number of men doing testosterone supplementation over the last decade. Ideally, this would mean scores of men were now benefiting from greater awareness and treatment of a chronic medical condition that has been historically under recognized. Unfortunately, flawed studies which link testosterone supplementation to an increased risk of cardiovascular events, an epidemic of abuse in professional sports, and occasional instances of irresponsible prescribing have turned testosterone into a dirty word.
Maintaining a normal testosterone level can be critical to a man’s health. Having too little testosterone can have profound effects on their quality of life. Sexual function, muscle development, cognition, and red blood cell production are a few of the more common health effects.
Testosterone supplementation for appropriate patients can be like turning the lights on after years of darkness
All men experience some decline in testosterone levels as they age. For some men the loss of testosterone production occurs at an early age. Others are particularly sensitive to below-normal levels of the hormone. Testosterone supplementation for appropriate patients can be like ‘turning the lights on after years of darkness,’ as one patient described it to me.
The symptoms of low testosterone are notoriously vague. Loss of sexual desire, erectile dysfunction, diminished energy level, difficulty concentrating, and sleep disturbance are probably the most common. However each of these symptoms can find route in innumerable medical conditions unrelated to testosterone production. That’s why a thorough evaluation by a physician is important before undertaking any treatment.
As the use of testosterone products has become more commonplace, so too has the knee-jerk reflex to attribute all manner of symptoms to ‘Low-T.’ To be sure, testosterone supplementation should not be misconstrued as an elixir for restoration of youth.
Testosterone supplementation is always in addition to healthy lifestyle changes, never in lieu of them
I tell my patients their own natural testosterone production can be buoyed by the adoption of healthy lifestyle choices such as daily exercise and a balanced diet. In some circumstances, this alone should be considered as a treatment option before taking medication. If we decide to begin testosterone supplementation, it is always in addition to heathy lifestyle changes, never in lieu of them.
Once suspicion of symptomatic low testosterone is confirmed with appropriate bloodwork and the decision is made to begin testosterone supplementation, the selection of a testosterone product can begin. Most Americans are accustomed to taking pills for almost anything. Unfortunately, pills for testosterone supplementation don’t exist. Patients must choose from an increasing number of delivery platforms, each with potential advantages and disadvantages.
Numerous testosterone gels exist and have the advantage of offering men an easy application and constant dose of testosterone. Unfortunately, they require daily application, can have an objectionable odor, and are unevenly absorbed in some men. Topical testosterone also carries the risk of transmission to a female partner if there is skin-to-skin contact before the medication has been completely absorbed. A testosterone patch eliminates the odor and resolves the problem of transmission to a female partner, but still requires daily application. For men who are simply uncomfortable wearing a patch all day they can choose a different delivery option.
Intramuscular injection is a popular choice, but prone to producing ‘peaks and troughs’ (abnormally high or low testosterone levels) in the days just after or just before the injection. Some men find the periods of low testosterone preceding their injections to be particularly bothersome. Additionally, there is the burden of intramuscular injections every 1-2 weeks, a daunting proposition for those unaccustomed to needles.
A new nasal spray has been approved but requires dosing three times per day. For many men, this is simply not feasible.
For my patients, the best option for testosterone supplementation is the subcutaneous pellet implant. After we numb the insertion site the pellets are placed under the skin with a tiny stab incision. The implantation procedure takes approximately 15 minutes and typically provides consistent testosterone levels in the target range of 400-600 ng/dL for about 4 months.
Patients find pellet implants to be the most convenient and reliable way to maintain their testosterone levels
Patients may report some soreness at the injection site for a few days after the implant. I have seen rare cases of infection or extrusion of the pellets. In my experience, patients find pellet implants to be the most convenient and reliable way to maintain their testosterone levels.
Testosterone supplementation should be viewed as a lifelong commitment. That’s because once the body recognizes normal testosterone levels in the blood, it ‘turns off’ the normal signals that stimulate testosterone production. If turned off for too long, testosterone production may return to an even lower level than prior to starting treatment. The required commitment to treatment should not deter men from realizing the benefits of restoring a normal testosterone level. After all, it’s no different than treatment of any other chronic condition such as diabetes or high blood pressure.
Timothy Siegrist, MD
Middlesex Health Urology
520 Saybrook Road
Middletown, CT 06457