Low testosterone has a damaging impact on many aspects of life. In fact, it can even shorten it. Why, then, is the subject of testosterone replacement therapy (TRT) still cloaked in stigma, confusion and damaging indifference?
“When I went to my GP, I had no idea I had just about every symptom of low testosterone. No mention was made of it. I did, though, leave with a prescription for anti-depressants!”
That’s Tom [38] and his story is not unusual. Researchers and medics appear divided on the statistics but it’s thought one and a half million men in the UK suffer from low testosterone while a huge number [90% has been suggested] go undiagnosed.
The medical profession routinely tests for conditions such as diabetes and thyroid [symptoms can be similar]. Low testosterone, though, gets short shrift.
Given it can lead to anxiety and depression, lack of concentration and motivation, loss of sex drive, poor [or non-existent] erections, debilitating exhaustion, low muscle mass, and hard to shift body fat [quite a list] what’s going on when it comes to diagnosis and treatment?
“There are some men – such as those who don’t produce testosterone because they were born with certain genetic conditions or had testicles removed due to cancer – where the decision to treat is clear,” says Dr Bonnie Grant, clinical research fellow at Imperial College London.
“Where it’s challenging is in men experiencing symptoms whose levels fall within a range of ambiguity. Studies have shown these are more likely to occur when those levels fall below a certain point [8nmol/L, for those of you into the science].
However, some men may have symptoms above this. It’s these men where we, as medical professionals, must think carefully. Testosterone levels are often a window into a man’s general health.”
Missing the symptoms
Dr Jeff Foster is a GP and specialist in men’s health with more than 20 years’ experience. Noting how testosterone replacement therapy (TRT) was overlooked by endocrinologists and urologists led him, a decade ago, to develop an expertise in the field.
He serves on the committee of the British Society of Sexual Medicine and is director of men’s health at the fully regulated Manual, the health and wellbeing platform with more than 10,000 TRT patients.
“Many men with low testosterone are prescribed antidepressants instead of investigating hormonal imbalances. In addition, current NHS guidelines on testosterone deficiency vary regionally and cut-off points are low, meaning many symptomatic men are dismissed,” he says.
More worryingly, there is evidence suggesting low testosterone can lead to a shorter life. Researchers [there are various papers available] found ‘low’ levels can be linked to an increased risk of all-cause mortality whilst levels deemed ‘very low’ are associated with a heightened risk of cardiovascular death.
What about the symptoms, because some might be simply indicative of our frenetic world?
“We know certain symptoms linked to low testosterone are around sexual function, specifically the loss of morning erections,” says Grant.
“The others could be due to myriad reasons. For example, men who are obese are 13 times more likely to have low testosterone and losing weight may well improve levels without the need for medication. Low libido and erectile problems may also be due to psychological rather than physical factors.”
Dr Jeff Foster agrees but offers an additional perspective.
“TRT is where menopause treatment and understanding was 10 to 15 years ago and, yes, there are issues around stereotyping. Most men seeking TRT are not gym-goers looking for muscle gains but rather normal guys struggling with fatigue, brain fog, mood swings, and anxiety. While loss of libido and erectile dysfunction are symptoms, they’re not the primary concern of most patients.”
What are the effects?
Given our brains and bodies are smart, what happens when a man starts TRT?
“The brain receives signals alerting it to the treatment and immediately switches off production of natural testosterone as well as sperm, something that obviously has implications for any man who wants to father a child imminently,” explains Grant.
“In my early twenties I craved that lean, muscular physique so I tried TRT,” says Josh [26]. I stopped a year later because I couldn’t see the results. But more than anything I didn’t like the idea of taking a substance that messes with something as basic as my sperm production. I eventually want kids so, for me, it’s a risk I wasn’t prepared to take.”
When it comes to other side effects there is much that remains unproven. However, it would be wrong to ignore sleep apnoea, acne, the stimulation of non-cancerous prostate growth, enlarged breasts, impeded sperm production, and testicle shrinkage have all been cited.
“Under correct medical supervision, these risks are managed and rarely seen. The key is to ensure you are monitored by a specialist,” says Foster.
“While it’s not for every man, those with a proven need for TRT experience significant improvements in quality of life. The challenge is raising awareness, breaking stigma, and ensuring access to proper diagnosis and care.”
Tom was eventually diagnosed with low testosterone [he never took the anti-depressants]. and began treatment under medical supervision. He calls it a “game-changer”.
“My sex drive and erections weren’t what they were. But it wasn’t that. What was seriously getting me down was mood swings, anxiety, lack of focus and always feeling exhausted. I’d lost my buzz for the gym, my lack of concentration could have become career damaging, and I had a general apathy about life. And then I’d get randomly tearful and think what the fuck is going on with me?”
“I feel so much better generally. My concentration has improved, I have more enthusiasm and I’m less anxious. When I faced problems in the past – even minor ones – I’d be like a rabbit in the headlights; now I can sit calmly and ask myself rationally, ‘okay, how do I handle this?’”
A long way to go
There remain far-reaching medical implications around the currently confused TRT debate, cautions Foster.
“Studies estimate 11 to 12% of men over 40 have low testosterone as do 40% of men with type 2 diabetes so, in total, we could be looking at one and a half million men in the UK with this hormonal imbalance. My profession needs a more flexible position when it comes to testing and diagnosis. And we really shouldn’t have men given anti-depressants as an almost default option to their symptoms.
“As another example, I had one elderly patient who was told he had dementia when, in fact, it turned out he had low testosterone. With treatment, his transformation was amazing.”
For 45-year-old father of three Will it was frustration when it came to losing weight – despite a disciplined training schedule and on-point diet – that led him to TRT.
“I’d always been active, but in my thirties life changed when family came along. Around the same time, I went vegetarian and started eating more carbs. The cumulative result wasn’t good. My weight ballooned, I had no motivation, I was constantly lethargic and it felt as if my cognitive abilities had shut down,” he says.
“My visceral fat had risen to a damaging level but I felt out of options as nothing worked. I started researching TRT but, for the average guy, it’s a confusing and contradictory topic.
“When you’ve always taken care of yourself in terms of exercise and diet, low testosterone sucks. Who wants to have no energy, greatly reduced focus, mood swings, and feel generally shit when you could still have 20, 30, 40 years ahead of you? And, although it was never my main worry, let’s face it, being unable to get or stay hard doesn’t do much for your self-esteem.
“I’ve been on TRT for two years and it’s like someone switched on a light. I’m more focused and have greater energy for life generally. Most importantly, my visceral fat has dropped from 42 to 12.”
No one-size-fits-all solution for testosterone replacement therapy (TRT)
Individual responses to TRT vary. Some men experience benefits quickly while others need dosage adjustments and, because not all men are suitable candidates, pre-screening is crucial.
“Many patients report significant improvements in wellbeing, confidence, and motivation but monitoring is essential,” says Foster. “TRT requires regular blood tests to ensure optimal levels and continued safe usage.”
“As with many medical concerns, there is usually a role in firstly looking at general health and lifestyle,” adds Grant. “If you have, and concerns persist, then you should ask your doctor about testing. It’s important your blood levels are checked when fasted, in the morning before ten, and on at least two occasions, to ensure an accurate result.”
TRT is a thorny topic to address without acknowledging that while many take it under medical guidance, diagnosis and treatment is often met with short shrift from GPs, leading to illicitly sourced and unsupervised use.
“Clearly, the biggest concern here is you probably have no idea what you’re injecting into yourself. We know of one ingredient never tested in humans finding its way into non-pharmaceutical grade substances,” says Grant.
Foster agrees, adding: “You must address lifestyle first. If symptoms persist, get tested and make sure that includes your ‘free’ testosterone level as this is often overlooked in standard NHS tests. Always seek treatment from reputable medical professionals rather than self-administering unregulated substances.
“TRT really is a safe and life-changing therapy for the right patient.”
