A 66 year old man saw his doctor for trouble with erections and low sexual desire. His doctor found nothing abnormal on examination, but the blood concentration of testosterone, a male hormone, was low. The patient was given testosterone supplementation in the form of a gel applied to the skin. Several months later, he had normal sexual function and improved strength, energy, and mood.
Testosterone deficiency like this is not rare in middle aged and older males. Because testosterone levels in men gradually decrease with age, abnormally low levels are seen in 4% of males between ages 40 and 70, and in a higher proportion of men over age 70.
Testosterone deficiency in males can cause loss of energy, depression, decreased sexual desire, trouble with erections, decreased strength, increased fat mass, and low bone density. Testosterone supplements improve most of these problems.
However, there hasn’t been enough good quality research on testosterone deficiency in older males to give us clear guidelines on how to diagnose and treat this problem. For example, there is no agreement among experts on what should be considered a low testosterone level. Some experts use 300 ng/ml and some use 200 ng/ml. Neither is there agreement on how many symptoms of testosterone deficiency should be present before testosterone supplementation is justified.
There are potential risks associated with testosterone treatment. The potential risk of most concern is a possible increase in the risk of prostate cancer. Other potential risks are an increase in the red blood cell count, breast enlargement, acne, mild weight gain, leg swelling, appearance of or worsening of sleep apnea, and a decrease in the size of the testicles. Fertility is impaired while testosterone supplements are given. Patients must be monitored carefully during testosterone supplementation.
Men who definitely should not receive testosterone supplementation include those with prostate cancer, a history of prostate cancer, an elevated PSA (the blood test for possible prostate cancer), or an abnormal prostate exam (nodule or enlargement) without an evaluation by a urologist to rule out prostate cancer. There are some other medical conditions which may make testosterone supplementation inadvisable, but the risks of not treating testosterone deficiency are also potentially serious. In general, testosterone supplementation is well tolerated in men with testosterone deficiency and is often dramatically effective.
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