When men experience a drop in energy, mood and sex drive, or struggle to put on the amount of muscle seen on movie stars and influencers, the finger is often pointed at low testosterone. And thanks to promotion by podcasters and proliferating men’s health clinics, “boosting” your levels with testosterone replacement therapy (TRT) is seen as a holy grail for improving men’s health. For men who actually have low testosterone, TRT is a game-changer. For those who don’t, there are risks.
So, what exactly is testosterone replacement therapy (TRT) and how do you know if you need it?
What is testosterone replacement therapy (TRT)?
Testosterone replacement therapy (TRT) is a medical treatment that replaces testosterone in men with androgen deficiency or low testosterone.
Testosterone is the main androgen (sex hormone) in men. It drives the physical changes that happen during male puberty, and it is needed to help regulate things like sperm production, bone health, muscle mass and sex drive. It’s important for normal development and overall wellbeing, so you need a healthy level of it.
Androgen deficiency is when the body does not make enough testosterone, which has wide-ranging effects on wellbeing. Androgen deficiency is caused by low testosterone production by the testicles. This can be due to the testicles themselves not working properly (known as primary hypogonadism), or because there’s a problem with the production of the hormones that control the testicles’ function (secondary hypogonadism).
Having a lower-than-normal testosterone level does not necessarily mean you have androgen deficiency. Low testosterone can be caused by short-term or long-term illnesses, such as an infection or diabetes.
Klinefelter syndrome and TRT
Klinefelter syndrome is a condition in which you’re born with an extra X chromosome that affects around one in 600 men. It’s significantly underdiagnosed with less than half of men with Klinefelter syndrome found across their lives. The effects of Klinefelter syndrome can vary quite a bit between different people and sometimes symptoms can be so mild in some individuals that they, their parents and their doctors may not even realise they have the condition. Having small testes (about the size of a grape) after puberty is a strong indication of Klinefelter syndrome. Other symptoms can vary but include being taller-than-average height, having reduced facial and body hair reduced muscle strength, and gynaecomastia. Maintaining a normal testosterone level using testosterone therapy is important for men with Klinefelter syndrome. Not only does it improve quality of life, but the condition is associated with several health problems, which are usually successfully treated with testosterone therapy.
Is testosterone replacement therapy safe?
TRT is very effective for those who have low testosterone. For these men, we know the benefits of the treatment are substantial and outweigh the risks. Not only does it improve quality of life, but it can also address health concerns associated with low testosterone.
But for others, it can be unnecessary and even dangerous. Misusing or abusing testosterone has been linked to serious conditions, including cardiovascular disease, liver damage and brain damage, with side effects including gynaecomastia, acne and infertility.
Don’t we all have low testosterone these days?
A series of studies shows decade-on-decade decreases in testosterone in men, suggesting today’s average man may have lower testosterone than his counterpart 50 years ago. Some claim that this “low-T epidemic” signals a male health crisis, however, the participants still had testosterone levels in the normal range despite them being lower. But some studies suggest there is a higher prevalence of clinically significant low testosterone.
These studies also do not tell us the cause (or causes) for this decrease in testosterone levels. Things like diet, physical activity levels, alcohol and other drugs, sleep, environmental exposures, and chronic diseases like high blood pressure, diabetes, overweight and obesity and stress can all affect testosterone levels. The prevalence of these health issues and habits has all changed during the last 50 years, and many of these behaviours we can change ourselves (rather than resorting to tanning our knackers).
Symptoms of low testosterone include low energy levels, mood swings, irritability, poor concentration, reduced muscle strength and low sex drive. These symptoms often overlap with other illnesses, so it’s important to figure out the cause with the help of a health professional, rather than self-diagnosing and seeking out testosterone as a cure-all.
But I’ll need TRT as I age, right?
If you maintain a healthy weight and remain disease-free, you’re unlikely to see a significant drop in testosterone levels or require testosterone replacement therapy.
There is no such thing as ‘male menopause’ or ‘andropause’. As men age there may be a small, gradual drop in testosterone, but this is often due to the effects of other conditions, such as obesity or diabetes. Being overweight and carrying weight around your waist is linked to lower testosterone levels, and weight loss can help increase testosterone.
Accessing TRT in Australia
In Australia, TRT must be prescribed by a medical practitioner, usually a GP, after evaluation by a specialist in sexual medicine or endocrinology, or by a urologist. Testosterone is illegal to possess or supply without a prescription or permit in Australia.
Your doctor can check your testosterone levels with a blood test, along with other hormones that might affect them. It’s best to have the blood test early in the morning while you are fasting. This is the best way to get a reliable measurement of your testosterone level. Testosterone levels can vary over time, so if you have a low level on one blood test, a second test is needed to confirm low levels.
A diagnosis of androgen deficiency is not just based on a blood test but includes a number of assessments, including a full medical history, physical examination and other tests.
TRT can be administered through regular injections (the most common method), skin creams or gels, or oral tablets. Once started, testosterone therapy is usually continued for life with strict monitoring.
If you are planning to try to have a child, your doctor won’t prescribe testosterone therapy.
Men on testosterone therapy are monitored regularly. Three to six months after starting treatment, you’ll need a repeat testosterone measurement, complete blood count, digital rectal examination and a prostate-specific antigen (PSA) test. If you have an increase in haematocrit to greater than 54% your doctor will advise you to stop treatment, lower the dose or change to a lower-risk formulation. If you have an increase in PSA of greater than 1.4 ng per mL (1.4 mcg per L) over 12 months or an abnormal digital rectal examination result you’ll be referred to a urologist.
If you have symptoms of low testosterone or concerns about your levels, see a doctor.
