Testosterone Deficiency

Testosterone Deficiency Syndrome (TDS) or hypogonadism occurs when the body does not produce enough testosterone. It may result from issues in the testes (primary hypogonadism) or problems in the hypothalamus or pituitary gland that control testosterone production (secondary hypogonadism).

While testosterone levels naturally decline with age, a significant drop that leads to symptoms is not considered a normal part of aging and should be evaluated by a healthcare professional.

The normal range of total testosterone in adult men is approximately 300 to 1,000 ng/dL. Levels can vary due to age, time of day, medical conditions, medications, and individual health.

In women, normal testosterone levels range from 15 to 70 ng/dL. Although less discussed, women can also suffer from testosterone deficiency.

• Klinefelter syndrome (genetic condition)

• Undescended testicles

• Mumps orchitis (mumps infection affecting testicles)

• Hemochromatosis (iron overload damaging testes)

• Testicular trauma or surgery

• Radiation or chemotherapy affecting the testes

• Pituitary tumors or disorders

• Kallmann syndrome (genetic disorder)

• Obesity

• Chronic illnesses like HIV/AIDS or liver/kidney disease

• Medications, especially corticosteroids and opioids

• Stress and excessive exercise

• Sleep disorders, including sleep apnea

Testosterone levels decline approximately 1% per year after age 30. This age-related decline is sometimes referred to as Late-Onset Hypogonadism.

The signs of low testosterone can be subtle and often overlap with other conditions, making diagnosis challenging.

Sexual Symptoms

• Decreased libido (sex drive)

• Erectile dysfunction

• Reduced spontaneous erections

• Infertility

• Reduced semen volume

Physical Symptoms

• Increased body fat, especially around the abdomen

• Reduced muscle mass and strength

• Decreased bone density (osteoporosis)

• Fatigue and low energy levels

• Gynecomastia (breast development in men)

• Hair loss

• Hot flashes or night sweats

Cognitive and Emotional Symptoms

• Depression

• Irritability

• Poor concentration and memory

• Low motivation or confidence

• Sleep disturbances

Testosterone Deficiency in Women

Though testosterone is more prominent in men, it also plays a role in female health:

• Libido and sexual satisfaction

• Bone and muscle strength

• Mood regulation

Women may experience low testosterone after menopause, oophorectomy (removal of ovaries), or due to adrenal insufficiency.

Symptoms include fatigue, reduced sexual desire, mood swings, and difficulty building muscle mass.

Diagnosis involves a combination of clinical evaluation and laboratory testing.

Step 1: Medical History and Physical Exam

• Review of symptoms

• Lifestyle and sexual health questions

• Physical signs like decreased muscle mass, testicular size, or body hair

Step 2: Blood Tests

• Total testosterone (measured in the morning when levels are highest)

• Free testosterone (if total testosterone is borderline)

• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to distinguish primary vs. secondary hypogonadism

• Prolactin, thyroid function tests, and iron studies

• Pituitary imaging (if pituitary disease is suspected)

A diagnosis is typically made when total testosterone is consistently below 300 ng/dL in men, along with relevant symptoms.

If left untreated, testosterone deficiency can lead to long-term health complications:

• Osteoporosis and fractures

• Anemia

• Obesity and metabolic syndrome

• Type 2 diabetes

• Cardiovascular disease

• Erectile dysfunction

• Depression and cognitive decline

It also affects quality of life, productivity, and interpersonal relationships.

1. Intramuscular Injections

   • Commonly used (e.g., testosterone enanthate or cypionate)

   • Given every 1-4 weeks

2. Transdermal Gels or Creams

   • Applied daily to skin (arms, shoulders, or abdomen)

   • Consistent levels but potential skin-to-skin transfer risk

3. Testosterone Patches

   • Applied nightly; steady delivery

4. Subcutaneous Pellets

   • Implanted under the skin every 3-6 months

5. Oral Testosterone

   • Less common due to liver impact

6. Nasal Gels

   • Multiple daily doses; newer option

Monitoring and Safety

Patients on TRT require regular follow-up:

• Testosterone levels

• Hematocrit and hemoglobin (risk of polycythemia)

• Prostate-specific antigen (PSA)

• Liver function tests

• Lipid profile

Risks and Contraindications of TRT

Contraindications

• Prostate or breast cancer

• High hematocrit levels

• Severe sleep apnea

• Uncontrolled heart failure

• Infertility concerns (TRT suppresses spermatogenesis)

Possible Side Effects

• Acne or oily skin

• Breast enlargement

• Shrinking testicles

• Infertility

• Mood swings or aggression

• Blood clots

• Sleep apnea worsening

Always consult a specialist (urologist, endocrinologist) before initiating TRT.

Alternative and Adjunctive Treatments

For some men, especially younger ones or those wishing to preserve fertility, alternatives may be appropriate:

• Clomiphene Citrate: Stimulates natural testosterone production

• hCG (Human Chorionic Gonadotropin): Supports testicular function

• Aromatase Inhibitors: Prevent conversion of testosterone to estrogen

Lifestyle changes are also essential, either alongside or instead of medication.