WHAT KIND OF MEDICAL PROVIDER SHOULD YOU SEE TO DIAGNOSE AND TREAT LOW-T?
Diagnosing and treating low testosterone (Low T) is an area of medicine that most physicians are not well versed in. Primary care physicians do not routinely check testosterone levels, let alone Free Testosterone or Sex Hormone Binding Globulin (SHBG) levels. Most are unfamiliar with the medical workup necessary to make the diagnosis and how to properly monitor patients under treatment. Many are hesitant to treat symptomatic patients with “Low Normal T”.
Testosterone replacement therapy (TRT) is a primary focus of the Charleston Men’s Clinic. Our medical director is a Board Certified Specialist in Internal Medicine with over 3 decades of clinical experience.
He’s not a chiropractor, surgeon, ER doc, physical therapist, aesthetician, etc. with little formal training and experience.
He is expert in diagnosing hypogonadism and deficient testosterone biosynthesis.
He treats hundreds of patients with Low-T, not just a few.
He isn’t busy doing other things like Botox injections, face and breast lifts, freezing fat and growing hair.
The Clinic is 100% male staffed and man-friendly.
We work with each patient to design a program that meets his specific needs.
We treat Low-T using injectable testosterone, topical cream or pellets. You can choose between home or office treatment for the injectable route.
Cost is affordable and competitively priced. Clinical progress is carefully followed.
Treatment safety is ensured by frequent, comprehensive laboratory monitoring.
In order to ensure the highest level of accuracy, all of our testing is performed by LabCorp, the world’s largest laboratory.
You can get your lab drawn in our office or go to a more conveniently located LabCorp facility.
Test results and dose adjustments are communicated directly to the patient.
We are happy to keep your other caregivers in the loop or we can keep your treatment totally confidential.
WHAT IS TESTOSTERONE?
Testosterone is a very important hormone. Hormones are special chemical messengers (signaling molecules) produced by special groups of cells in our body called endocrine glands. They regulate and control most major bodily functions. Hormones are secreted directly into the blood and then transported to specific cells or tissues in the body to stimulate them into action. When they are in proper balance, hormones help the body thrive, but small variations in hormone levels can cause serious and life-altering symptoms.
Testosterone is the primary male sex hormone. It is mostly made by in the testicles and, to a much lesser extent, in the adrenal glands. It is secreted directly into the blood.
It is responsible for the normal growth and development of the sex organs, secondary sexual characteristics (such as facial and body hair and deepening of the voice) and to a large extent, determines our sex drive. But, testosterone is much more than just a “sex” hormone. It also contributes to essential body functions such as cognition, mood, sleep cycles, energy level, red blood cell production, muscle mass, fat deposition and bone density.
After the age of 30, men begin to experience an average 1% or more per year decline in their testosterone level. This really adds up over time and has significant quality of life effects as we live increasingly longer.
Other factors besides age, such as health and lifestyle can lower testosterone levels even further.
Alarmingly, a separate, generational, age-independent decline in testosterone levels (and also seen in sperm counts) has been observed in American men over the last few decades.
This additional decrease has not received much attention in the press or even the medical literature.
It can not be fully explained by the health and lifestyle changes that have occurred in the population over time (such as increased obesity, people taking more medications, less smoking etc.). A decline persists even after adjusting for these variables.
This added decline in testosterone levels is not trivial. Laboratories have had to adjust their “reference range” (see below) to reflect this decline. Within the last year, LabCorp’s reference range for total testosterone went from 348-1197 ng/dL down to 264-916 ng/dL. That’s a 24% decrease!
To put this in perspective: If you had a testosterone level last year of 300 ng/dL, you would have been diagnosed as “Low’T”. But this year, that same value indicates that you’re “normal”. Really?
BIOAVAILABLE TESTOSTERONE VERSUS TOTAL TESTOSTERONE
Testosterone is a non-polar or lipophilic hormone derived from cholesterol. Because it is not water soluble, almost all of it attaches to carrier or transport proteins to allow it to travel in the bloodstream. The two proteins it binds to are albumin and sex hormone-binding globulin (SHBG). Before it can leave the blood vessels to get to the target tissues (muscle, bone, brain, etc) where it produces its effects, the testosterone needs to break free from the transport protein. Testosterone is weakly bound by albumin and along with free testosterone is bioavailable to the tissues. But the testosterone bound to SHBG can’t break free and diffuse into the tissues and is not bioavailable. Generally speaking, about 65 percent of the testosterone is bound to SHBG, 30 to 40 percent is bound to albumin, and about 2 percent is unbound or free. As we get older, we make more SHBG, so a smaller percentage of the total testosterone is bioavailable.
The total testosterone level in the blood measures the sum of all three of these and therefore includes both the bioavailable testosterone and the non-bioavailable testosterone.
We are interested in determining the bioavailable fraction. Measuring the bioavailable testosterone from a blood specimen directly is technically difficult and very expensive.
Measuring the free testosterone in addition to the total testosterone provides a much better assessment of bioavailable testosterone and that’s what we do at the Charleston Men’s Clinic.
Lower levels of testosterone can result in numerous physical and psychological symptoms.
- Loss or decrease of libido (sex drive)
- Decrease or loss of morning erections
- Fatigue or decreased energy
- Decreased muscle mass and strength
- Weight gain and increased central body fat
- Decreased athletic and physical ability
- Decreased stamina and endurance
- Decreased motivation, self-confidence and productivity
- Poor concentration and memory
- Feeling sad or depressed
- Decreased body hair
- Osteoporosis and bone fractures
- High cholesterol
- Sleep disturbance and daytime sleepiness
If you’re experiencing some of the symptoms listed above and your testosterone level is not optimal, you may benefit from testosterone replacement therapy (TRT).
IS A REFERENCE RANGE THE SAME AS AN OPTIMAL RANGE?
No. A reference range tells you the range that by design includes 95% of a reference population. An optimal range defines what is a healthy range for you as an individual.
WHAT IS A REFERENCE RANGE?
A reference range (interval) is a mathematical way of looking at the test results of a large sample of the population. When you plot all the test results of a given population on a graph, they almost always distribute in the familiar appearing “bell shaped curve”. Testosterone levels follow this pattern of distribution.
The average value (mean) is in the center at the top of the curve and the remaining values distribute out symmetrically on each side. The curve can be analyzed statistically and predictable “standard deviations” from the mean can be calculated. One standard deviation from the mean will include about 68 percent of the population and two standard deviations will include 95 percent.
The “reference range” for testosterone is nothing more than the upper and lower limits of two standard deviations from the mean or the middle 95% of this population.Only 2.5% of this population falls below the lower limit and only 2.5% of this population falls above the upper limit. If you compare your testosterone level to this range and you fall within or above the range, it just means that your testosterone level isn’t in the bottom 2.5% of the population.
The reference range for testosterone is quite large. The specific limits vary from lab to lab, but there is always a 3-4 fold difference between the upper and lower limits. In other words, if you’re at the low end, you have only 1/4 to 1/3 the amount of testosterone the guy at the other end has. That’s a pretty huge spread. Sign me up for the upper end!
HOW IS “LOW-T” DIAGNOSED?
Unfortunately, the “reference range or interval” for testosterone is mistakingly generally regarded as the “normal range”. This would imply that exactly 2.5% of the reference population has Low-T and everyone else is normal or above normal. This approach does not factor in how each individual feels or is performing. It does not recognize that each of us is unique and that we each have our own “sweet spot” where we function optimally. An astute physician treats the patient, not a number on a graph. What is normal for one man, may be low for another.
OPTIMAL vs LOW-T
Insufficient levels of testosterone may lead to symptoms including lowered sex drive, ED, decreased energy, fatigue, increased body fat, weakness, decreased motivation, initiative and self-confidence, osteoporosis, anemia, etc.
Let’s say that you have symptoms of Low-T and your testosterone level is 300 with a reference range of 250-900. Wouldn’t it be reasonable to see how you feel at a higher level of testosterone that’s still “in range”? Too many physicians (and virtually all insurance companies) would refuse you treatment because “you’re normal”.
Doctors don’t treat all lab values this way.
We don’t just tell a symptomatic post-menopausal woman with hot flashes, low sex drive and pain on intercourse that her estrogen level is normal for her age and to just live with her symptoms.
Likewise, cholesterol measurements in the population follow a normal bell-curve distribution, but we don’t tell patients their level is “normal” or “optimal” whenever it falls within 2 standard deviations from the mean.
It is estimated that 50% of the American population have cholesterol levels that are above an accepted “healthy range”, not just the 2.5% below 2 standard deviations from the mean.
We would also do further testing looking at HDL, LDL and triglyceride levels and evaluate the entire clinical picture paying careful attention to medical history, family history, risk factors, etc. before making dietary, lifestyle and medication recommendations.
I’m sure that you would consult a specialist if your primary physician handled your cholesterol this way.
Why wouldn’t you do the same with your testosterone?
WHO SHOULD BE TREATED?
- If your testosterone is truly low, and there are no medical contraindications to treatment, you should almost certainly go on TRT to prevent problems like osteoporosis and anemia. Very low levels may also need further workup such as a brain MRI looking for a possible pituitary tumor.
- If you are asymptomatic and your testosterone is clearly within the reference range, then you should probably not go on TRT. Legitimate doctors do not prescribe TRT for performance enhancement body building.
- If you are symptomatic and your testosterone level is on the low side of the bell-shaped curve, TRT may be indicated. Optimized testosterone levels often lead to a fuller, more vigorous experience of day to day life.
TRT is safe and effective if it is done properly. If not done right, and hormonal imbalance occurs, serious health consequences can result. That’s why it is so important to be treated by a health team that knows what it’s doing and you can trust.
How do you feel? Is it time for you to get back in the game?