Disorders of the Testicular Function
Testicular Function Overview:
The male sex hormone (androgen) testosterone, produced by the testes under control of the pituitary is essential for the maintenance of masculine characteristics and male sexual function.
Testosterone production increases at the onset of puberty and reaches a peak in the late teens. While not as dramatic and sudden as the female menopause, for many years it has been accepted that circulating testosterone levels decline with increasing age. The terms male menopause, andropause, late onset hypogonadism (LOH), testosterone deficiency syndrome (TDS) and partial androgen decline in the aging male (PADAM) are all used to describe this decline in testosterone levels with advancing age. After the age of 50 years, levels fall by approximately 1% a year resulting in 20% of men over 60 having frankly low levels. However, due to the complexity by which testosterone interacts with other hormones which affect its biological activity, up to 70% of men over 60 years may have low levels of biologically active testosterone which are sufficient to cause symptoms. In fact, it wasn’t until the end of 2019 that scientists have determined typical serum total testosterone concentrations in healthy, never-smoking, lean men, that can be incorporated into guidelines for testosterone deficiency management.
Signs and Symptoms of low testosterone levels:
The symptoms associated with LOH can be divided into 3 main areas, those affecting sexual function, mood and cognition, and body characteristics:
While erectile dysfunction may be one of the most recognized symptoms, it is the decline in intellectual function and overall diminished zest for life which tend to be more common but usually elicited only on direct questioning. Due to the slow decline in testosterone levels, the onset of these symptoms tends to be insidious and otherwise attributed to ‘normal’ aging. Not all of these symptoms need be present for the diagnosis of LOH and the severity of one or more does not necessarily match the severity of the others.
Diagnosis and Tests
Confirmation of the diagnosis of LOH requires careful evaluation. Diagnosis is based on a confirmatory history and symptoms, physical examination and laboratory investigations done by a reputable laboratory.
Total testosterone blood levels below 230 ng/dL are generally accepted as being frankly low, and levels above 350ng/dL as being generally normal. Most symptomatic men will have testosterone levels in the gray zone between 230 and 350ng/dL.
Dr. Schneider will do additional tests if he suspects, that your low testosterone levels are secondary to other conditions like obesity, obstructive sleep apnea, pre-diabetes/diabetes, diseases of the liver, kidney, and heart/lungs, depression and anxiety or by long term use of opioids (like oxycodone), corticosteroids (like prednisone) or anabolic steroids.
Testosterone Replacement - is it the right treatment for you? What are the options?
The most important question is: do you need treatment? Dr Schneider will discuss in depth the risks and benefits of Testosterone replacement before beginning any treatment.
There are a variety of different ways of administering testosterone including injections (either 2-4 weekly or larger depot injections every 2-3 months), oral tablets, or transdermal (skin) preparations (gels). The choice of which route of administration depends on individual preference. We will choose the right regimen together so you can enjoy the best quality of life while being safe.
For patients with LOH, the benefits of testosterone therapy are usually rapid with marked improvement in many if not all the initial symptoms. In addition to improvement in sexual function, it is the restoration of overall intellectual function that many men find most gratifying combined with the return of their zest and motivation for life. Once improvement has been sustained patients often switch to longer acting depot injections which may be more convenient. Dr Schneider will adjust the dose to your response as well as by regular blood tests to try and restore testosterone levels to those of a young adult.
Safety, Risks and Side Effects of Testosterone Replacement
Testosterone therapy is generally safe and very well tolerated with few significant side effects but careful monitoring by a specialist is mandatory. Stimulation of red cell production by the bone marrow will often increase the blood count and on occasions this will increase the viscosity of blood (haematocrit) to an unsafe level (increased risk of a stroke) and therefore require a dose reduction. Liver function blood tests will also require monitoring. The biggest concern relates to the perceived risk of prostate cancer. However, contrary to earlier reports, there is no evidence that testosterone therapy actually causes prostate cancer, and indeed rates of this cancer are actually increased in men with low testosterone levels. However, testosterone can worsen the disease in men who already have prostate cancer and for them it is contraindicated. Testosterone can also stimulate benign enlargement of the prostate gland and for this reason, Dr Schneider will order regular monitoring of prostate specific antigen (PSA) levels.
Does testosterone replacement cause infertility? Will the testicles shrink?
This sounds somehow paradoxical - but it is mostly correct. Testosterone replacement, i.e. the exogenous administration of testosterone will lead to a decrease in the pituitary hormones LH and FSH which, in turn, will considerably slow down sperm production in the testicles. Some decrease in testicle size has also been reported. Usually, fertility is restored upon stopping testosterone treatment, but sometimes this take time. If you are on testosterone replacement and are interested in fertility speak with Dr. Schneider about options to preserve fertility while on testosterone replacement.