How About "Low T"

In recent years we have seen a number of TV ads about how men of almost any age can suffer from low levels of testosterone, which may cause excess fatigue, depression, and even erectile dysfunction (ED). Blood levels of total testosterone are about usually about 700-900 (range 350-1200) and three percent of this should be free testosterone.

However, these levels vary from man to man at a given age level and throughout the spectrum of age levels. Much depends on symptoms, and this is why treatment needs to be adjusted partly based on lab values and partly on how a person responds to therapy with testosterone. In other words, what are the symptoms and what level of correction do you really need or want?

Interestingly, the benefits of treatment with bioidentical testosterone include better weight control, improved muscle mass and exercise tolerance, less risk of stroke and coronary artery disease, and improved cognition, to name a few. The literature on the matter is varied and depends on a large extent to the type of testosterone advertised plus route of administration. Oral testosterone or variations of the type of testosterone administered affect the outcome. Think natural testosterone by topical or by injection, and you will know the best form to use.

Other hormones come into play in both males and females, and we all have a balance of testosterone, estrogen, DHEA, and oxytocin. In women, at menopause the estrogen levels drop quickly, and the testosterone levels become more prominent. In men, there is a tendency to convert both DHEA and testosterone into estrogen, and this potentially can cause more risk of heart attack and stroke. Therefore, estrogen levels should be tested and, if high, a drug taken weekly (Arimidex®) will reduce the conversion of testosterone to estrogen. Heart disease is associated with total testosterone levels below 332, and lower rates are seen with total testosterone over 500.

The level to which testosterone should be replaced is about 700-900, and only above 550 will positive cardiovascular changes occur. Multiple studies have confirmed this, and also show reduced LDL, reduced C reactive protein, reduced HgA1c, and increased HDL.

The question is should women receive testosterone as part of hormone replacement therapy? If so, what route and what dosage should be administered? Injections given weekly or biweekly tend to give peaks and troughs, whereas gel or cream can provide bioidentical testosterone, which is gradually released into the blood stream on a daily even basis. Androgel® or a compounded version is the usual treatment of choice

How about testosterone for women as an adjunct to HRT including estradiol and progesterone? We do know that low testosterone levels in women can be associated with a low sex drive, decreased energy, and decreased physical strength. At present, there are no FDA recommendations for use of testosterone in women, but there is one female hormone that includes estrogen and testosterone. Contraindications include breast cancer, liver cancer, and pregnancy. Side effects from a dose which is too high include acne, excess body hair, irregular menses, and aggressive personality.

In my practice of cosmetic plastic surgery, most postmenopausal women want to decrease abdomen fat, increase lean muscle mass and strength, and improve libido. Testosterone combined with standard HRT may help a patient to realize these goals.

In summary, if you are entering menopause, testing for estrogen, testosterone, and progesterone should be done. Symptoms should be documented well on a time-related basis. For men in andropause, levels of testosterone and estrogen should be measured and symptoms documented.

However, be careful to review the credentials of your provider because all of the ‘hype’ about ‘Low T’ is designed to make you want to go on testosterone, and treatment can be expensive and is usually not covered by insurance. There is some good evidence that the drug is being overprescribed and sometimes unnecessarily, but good testing and careful monitoring of treatment can sometimes contribute to quality of life and even better health.

Dr. Carraway is the director of the Plastic & Cosmetic Surgery Center of EVMS. Call 757-557-0300 for more information.

James H. Carraway, M.D.

Dr. James Carraway is a full-time academic and practicing clinical plastic surgeon.  He is Director of the Cosmetic & Plastic Surgery Center of EVMS, is board certified in surgery and plastic surgery, and is a fellow of the American College of Surgeons.  Dr. Carraway has been teaching and practicing for 30+ years and has been director and chairman of residency training programs and fellowship programs in plastic surgery.
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