Dr. T Hugh Jones

Centre for Diabetes & Endocrinology, Barnsley

There are two main causes of Testosterone deficiency:

• Primary - failure of the testis
• Secondary - failure of the Pituitary gland

A third, mixed Hypogonadism, can affect the older man.

Two sex-related hormones are produced by the pituitary gland:

• Luteinising hormone (LH) is the major stimulator of the testis
• Follicle Stimulating Hormone (FSH) stimulates the growth of the testes pre-puberty and initiates and maintains sperm production.

Testosterone levels vary with time according to the time of day and year. Shift work patterns can alter a man's regular cycle. You should give yourself about 6 days of 'normal' daily activity to return to your cycle before tests are done.

Therefore the timing of testosterone level testing is important. The test should be done before 10am on at least two occasions to measure an accurate reading that can lead to a diagnosis.

There is no 'normal' level for any given age but it is generally accepted that <10.4nmol/I indicates hypogonadism.

The ADAM (Androgen Deficiency in the Aging Male) Questionnaire can be used as an initial indicator of testosterone deficiency. Symptoms can include:

• Fatigue / lethargy
• Loss or reduction in libido
• Reduced strength of erections
• Moodiness / grumpiness

The consequences of low testosterone levels can have a wide-reaching effect on a man's life and well-being:

• Poor quality of life
• Loss of libido
• Marital disharmony
• Osteoporosis
• Debility
• Risk of chronic Heart Disease and diabetes

Physical symptoms experienced by hypogonadal men include a reduced sex drive and increased abdominal fat mass (the beer belly). A rare effect of very low testosterone can be Gynaecomastia - growth of breast tissue. Testosterone Replacement Therapy can help but the only solution to remove developed tissue is surgery.

Testosterone Replacement Therapy (TRT)

Therapy Options

There is choice available. One option is not necessarily better than any other. People are different and may choose how they take testosterone to fit their lifestyle and needs.

Intra-muscular Injections (Sustanon)

Given every two to three weeks at GP surgery - can result in peaks and troughs. Some men can suffer unpleasant swings of mood and performance.

Implants

Similar to the injections above but not subject to the frequency of cycles - peaks and troughs can be more apparent.

Tablets

Restondal - not usually recommended these days as the stomach destroys a big percentage of the dose given.

Scrotal patches

Still popular but can get lost.

Gel

Daily, rubbed on first thing in the morning, it dries in 5 minutes. Can be forgotten if not careful.

Buccal tablet

This tab sticks onto the gum and gradually dissolves over hours. Although some worry that they will lose the tab during the day, it sticks well and remains through eating and drinking.

Nebido

Injections that last for 3 months - an initial high is followed by a more constant mid-normal range. There is a 6-week initial load to build the normal cycle. Since injections are 4ml (as opposed to Sustanon's 1ml) these injections are always given at GP surgery.

These are the options that are available. Each method does the job of delivering testosterone. Testosterone helps keep people feeling well and happy.

For more information on Testosterone Replacement Therapies available, please go to our Drug Information page. If you are on Testosterone Replacement Therapy and would like a Testosterone Replacement Diary, please email helpline@pituitary.org.uk with the subject 'Replacement Therapy Diary'.