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Low Testosterone

Before embarking in the discussion of Low Testosterone or Low T also known as hypogonadism.  It is important to realize that at Brooklyn Urology, we strive to give our patients the most competent and safe care.  We always adhere to sound and proven scientific based clinical treatment protocols.  Whenever there are clinical guidelines, we adopt them into the practice.  Like with any treatment option in medicine,  there are risks and benefits that you, the patient, must understand and agree prior to start any therapy.

The treatment of Low T with Testosterone Replacement Therapy (TRT) is safe! Some people have tried to put the blame worsening of congestive heart failure (CHF), strokes and recent myocardial infractions (MI) on TRT.  Although SOME studies suggested some sort of relationship, existing research found little evidence of a connection between low testosterone and artherosclerosis, the hardening and narrowing of arteries that can cause heart attacks and strokes. The reviewed studies also found no relationship between testosterone levels and heart attacks.  At Brooklyn Urology we follow American Urological Association (AUA) and The Endocrine Society Guidelines for the treatment of patients with Low T.

 

What is Hypogonadism?

Gonadal deficiency, Hypogonadism, or Low Testosterone (Low T) occurs when the body’s sex glands produce little or no hormones. In men, these glands (gonads) are the testes. In women, these glands are the ovaries.

Symptoms

In boys, hypogonadism affects muscle and beard development and leads to growth problems. In men the symptoms are:

  • Breast enlargement
  • Decreased beard and body hair
  • Muscle loss
  • Sexual problems

As men age, hypogonadism can lead to decreased libido, worsening ED, weakness, hot flashes, memory loss and weakness.

Girls who have hypogonadism will not begin menstruating. Hypogonadism can affect breast development and height in girls. If hypogonadism occurs after puberty, symptoms include:

  • Hot flashes
  • Loss of body hair
  • Low libido
  • Menstruation stops

If a brain tumor is present (central hypogonadism), there may be:

  • Headaches or vision loss
  • Milky breast discharge (from a prolactinoma)
  • Symptoms of other hormonal deficiencies (such as hypothyroidism)

People with anorexia nervosa who diet to the point of starvation and those who lose a lot of weight very quickly, such as after gastric bypass surgery, may also  have central hypogonadism.

 

How to diagnose Low T or Hypogonadism?

It will be out of the scope of this article to discuss diagnosis of Low T in depth.  However, we will share with you the most important diagnostic tests that are needed to come up with different diagnosis.  After an appropriate history and physical, the hormonal blood level evaluation is extremely important step in the evaluation of low T.

In both men and women, testosterone and Estrogen production is under regulation and primarily controlled by the Hypothalamic-Pitutary-Gonadal axis system.

 

I will discuss this Axis in men.  The Anterior Pituitary  (AP) releases 2 hormones known as Leutinizing Hormone (LH) and Follicle Stimulating Hormone (FSH), which are under regulation by the Hypothalamus, a section in the brain, that releases Gonadotropin Releasing Hormone (GnRH). GnRH travels through very small vessels in the brain until it reaches the AP which in turns regulates the release of LH and FSH, both of which travel through the blood stream until they reach their designated target, the TESTIS (or Ovaries)! LH is the hormone that tells cells in the testicle to produce Testosterone (Estrogen in the ovary) while  FSH is in charge of sperm (follicle) production in the Testis (Ovary).  After Testosterone is secreted into circulation, it can also self regulate itself.  Too much T and it will send a signal to Slow down both the Hypothalamus and AP.

A deficiency of either GnRH or LH will result in a decrease level of Testosterone!

What are the different conditions that can affect Testosterone?

The best way to approach this question is to start from a broad to a more specific cause.  Is it a problem with the target Organ (Testis)? or is it a problem with either Hypothalamus or AP? Is it a lack or over productions of hormones that has lead to an imbalance?

Affected systems
Diagnosis What’s affected? Examples
Primary hypogonadism defects of the gonads (Testis) Klinefelter syndrome and Turner syndrome. Mumps is known to cause testicular failure, and in recent years has been immunized against in the US. A varicocele can reduce hormonal production as well.
Secondary hypogonadism
or central hypogonadism (referring to the central nervous system)
hypothalamic
or pituitary defects
Hypothalamic defects include Kallmann syndrome.
Pituitary defects include hypopituitarism.
Androgen insensitivity syndrome lack of hormone response, where there are inadequate receptors to bind the testosterone. Results in a female appearance despite XY chromosomes.

 

What are Causes of Low T?

The cause of hypogonadism is primary or central when the ovaries or testes themselves do not function properly. Causes of primary hypogonadism include:

  • Certain autoimmune disorders
  • Genetic and developmental disorders
  • Infection
  • Liver and kidney disease
  • Radiation
  • Surgery

The most common genetic disorders that cause primary hypogonadism are Turner syndrome (in women) and Klinefelter syndrome (in men).

In central hypogonadism, the centers in the brain that control the gonads (hypothalamus and pituitary) do not function properly. Causes of central hypogonadism include:

  • Bleeding
  • Certain medicines, including steroids and opiates
  • Genetic problems
  • Infections
  • Nutritional deficiencies
  • Iron excess
  • Radiation
  • Rapid, significant weight loss
  • Surgery
  • Trauma
  • Tumors

A genetic cause of central hypogonadism that also takes away the sense of smell is Kallmann syndrome in males. The most common tumors affecting the pituitary are craniopharyngioma in children and prolactinoma in adults.

 

What laboratory tests are performed to diagnose Low T or Hypogonadism?

Low testosterone can be identified through a simple blood test performed by a laboratory, ordered by a physician. This test is typically ordered in the morning hours, when levels are highest, as levels can drop by as much as 13% during the day.

Normal total testosterone levels range from 300–1000 ng/dL.

Levels of LH, FSH, Prolactin, Thyroid hormones and Sex binding globulin must be measured. Primary testicular failure or dysfunction is diagnosed when Testosterone is low, LH/FSH are elevated and Prolactin is normal.  A high level of Prolactin can give clues to a tumor in the Anterior Pituitary (AP) known as Prolactinoma that can occupy space in the AP causing the rest of the other hormones (LH/FSH) to decrease thus leading  to a low Testosterone.  Low levels of LH/FSH while low levels of Prolactin usually indicates Hypothalamic or Pituitary (central) Hypogonadism.

Does Brooklyn Urology evaluates, diagnose or treats patients with Low T?

YES!

Brooklyn Urology, is one of the premier urological practices that treat a large volume of patients with Low T. We offer all treatment option and have excellent results with hormonal replacement therapy. At Brooklyn Urology we follow American Urological Association (AUA) and The Endocrine Society Guidelines for the treatment of patients with Low T.

How is Low T treated?

Male hypogonadism is most often treated with testosterone replacement therapy (TRT) in patients who are not trying to conceive.  Commonly used testosterone replacement therapies include transdermal (through the skin) using a patch or gel, injections, or pellets.  Oral testosterone is no longer used in the U.S. because it is broken down in the liver and rendered inactive; it also can cause severe liver damage.

How is Testosterone Replacement Therapy (TRT) delivered?

– Intramuscular

– Transdermal Patches

– Topical gels

– Subcutaneous (below skin) pellets

– Testosterone buccal (mouth) system

               Androgel        Axiron
Testim Fortesta
Testosterone Pellets  Buccal system

 

 

 

Once I start treatment for Low T, can I see immediate results?

Like many hormonal therapies, changes take place over time. It may take as long as 2–3 months at optimum level to see an overall improvement especially to reduce the symptoms, particularly the wordfinding and cognitive dysfunction.Other symptoms make take shorter time to see an improvement.

Whats considered a good response when starting Testosterone replacement therapy?

Testosterone levels in the blood should be evaluated to ensure the increase is adequate. Levels between 500 and 700 ng/dL are considered adequate for young, healthy men from 20 to 40 years of age, but the lower edge of the normal range is poorly defined and single testosterone levels alone cannot be used to make the diagnosis. Modern treatment may start with 200 mg intramuscular testosterone, repeated every 10–14 days. Getting a blood level of testosterone on the 13th day will give a “trough” level, assisting the physician in deciding whether the correct dose is being given.