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What is testosterone deficiency(TD)
Low testosterone or hypogonadism, is a medical condition in which the testes (testicles, the male reproductive glands) do not produce enough testosterone (the male sex hormone).2-4 While it is common for testosterone levels to progressively decline in men as they get older,6 low testosterone can occur even in young men, especially if they have developed a belly or have an excess amount of total body fat.7 Other possible causes for low testosterone in younger men is life/work stress9 and use of medications, such as opioids,10 selective serotonin reuptake inhibitors (SSRIs)11 and statins.12 Therefore, low testosterone is not just an “old man’s problem”. Causes of testosterone deficiency in young men include underlying genetic conditions, environmental factors or past injuries and infections.13
Talking to your doctor
CONCERNED ABOUT TALKING TO YOUR DOCTOR? Read our tips on talking to your doctor about your symptoms
What are the signs & symptoms of low testosterone?
Metabolic symptoms / signs
- Obesity (BMI 30 or higher)
- Abdominal (belly) obesity (waist circumference 102cm or higher)
- Metabolic syndrome
- Insulin resistance, prediabetes or type 2 diabetes
- Decreased sexual desire and activity
- Decreased frequency of sexual thoughts
- Erectile dysfunction
- Delayed ejaculation
- Decreased volume of ejaculate
- Decreased frequency or absent morning or night-time erections
- Small testes
- Depressed mood
- Loss of energy
- Reduced motivation
- Poor concentration
- Decreased well-being and/or poor self-rated health
- Impaired memory
- Decreased cognitive function (including impaired concentration, verbal memory, and spatial performance)
- Decreased muscle mass and strength
- Reduced physical performance
- Hot flushes or sweats
- Sleep disturbances
- Reduced bone mineral density, osteoporosis,
low trauma fractures
- Decreased body hair
- Gynaecomastia (enlarged breasts)
What causes low testosterone?
Although many people think that the main cause of low testosterone is ageing, observational studies consistently show a strong association of obesity with low circulating testosterone levels in men.6,23,24
This means that by living a healthy lifestyle with regular exercise and healthy food habits, you improve your chances of maintaining your testosterone in the healthy range even as you get older. In other words, low testosterone – while common - is not inevitable in men as they get older, as menopause is in women.
Other possible factors for low testosterone the metabolic syndrome25-27 and type 2 diabetes.28-30 Chronic diseases, such as high blood pressure, heart disease, liver disease, kidney disease, arthritis, stroke, emphysema, rheumatoid arthritis and depression may also be risk factors for low testosterone.29,32
Which men are most at risk of TD?
Men with... Obesity
Men with... Erectile dysfunction
Among men with erectile dysfunction, over one third (36%) have low testosterone levels.9 Low testosterone can cause erectile dysfunction and/or non-responsiveness to treatment with PDE5i (phosphodiesterase 5 inhibitors) such as Viagra. Therefore, according to medical guidelines is it mandatory that men with erectile dysfunction have testosterone levels measured.39,40 This is particularly important if your erectile dysfunction treatment doesn’t appear to be working well.
Men with... Type 2 diabetes
Nearly half of men with type 2 diabetes have low testosterone.36 Obesity is common among men with type 2 diabetes,37 but even non-obese men with type 2 diabetes commonly have low testosterone.36 The frequent occurrence of low testosterone in men with type 2 diabetes prompted medical guidelines to recommend that testosterone levels are measured in men with type 2 diabetes who have symptoms.4
Men with... High work stress
Among men with sexual dysfunction, more than 40% who report a high degree of work stress have been found to have low testosterone.9
Think you’ve got low testosterone?
Regardless of age, if you’re rarely in the mood for sex and perhaps have difficulties getting an erection, often feel tired/lethargic and have a depressed mood, you may be experiencing symptoms of low testosterone.
- EAU Guidelines on Sexual and Reproductive Health, 3. Male Hypogonadism 2022. Available at:https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Sexual-and-Reproductive-Health-2022_2022-03-29-084141_megw.pdf. Accessed February 2022.
- Jayasena CN, Anderson RA, Llahana S, et al. Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism. Clin Endocrinol (Oxf). 2022;96(2):200-219.
- Hackett G, Kirby M, Edwards D, et al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. The journal of sexual medicine. 2017;14(12):1504-1523.
- Travison TG, Araujo AB, Kupelian V, O’Donnell AB, McKinlay JB. The relative contributions of ageing, health, and lifestyle factors to serum testosterone decline in men. J Clin Endocrinol Metab. 2007;92(2):549-555.
- Gapstur SM, Gann PH, Kopp P, Colangelo L, Longcope C, Liu K. Serum androgen concentrations in young men: a longitudinal analysis of associations with age, obesity, and race. The CARDIA male hormone study. Cancer Epidemiol Biomarkers Prev. 2002;11(10 Pt 1):1041-1047.
- Guay A, Seftel AD, Traish A. Hypogonadism in men with erectile dysfunction may be related to a host of chronic illnesses. Int J Impot Res. 2010;22(1):9-19.
- Bawor M, Bami H, Dennis BB, et al. Testosterone suppression in opioid users: a systematic review and meta-analysis. Drug Alcohol Depend. 2015;149:1-9.
- Atmaca, M. Neuropsychiatric disease and treatment, 2020;16,1043.
- Corona G, Boddi V, Balercia G, et al. The effect of statin therapy on testosterone levels in subjects consulting for erectile dysfunction. The journal of sexual medicine. 2010;7(4 Pt 1):1547-1556
- Cohen J, et al. Frontiers in endocrinology, 2020;10, 916.
- Dean JD, McMahon CG, Guay AT, et al. The International Society for Sexual Medicine’s Process of Care for the Assessment and Management of Testosterone Deficiency in Adult Men. The journal of sexual medicine. 2015;12(8):1660-1686.
- Morales A, Bebb RA, Manjoo P, et al. Diagnosis and management of testosterone deficiency syndrome in men: clinical practice guideline. Appendix available at: http://www.cmaj.ca/content/suppl/2015/10/26/cmaj.150033.DC1/15-0033-1-at.pdf (accessed Sept 17, 2019). CMAJ. 2015;187(18):1369-1377
- Wu FC, Tajar A, Pye SR, et al. Hypothalamic-pituitary-testicular axis disruptions in older men are differentially linked to age and modifiable risk factors: the European Male Ageing Study. J Clin Endocrinol Metab. 2008;93(7):2737- 2745.
- Camacho EM, Huhtaniemi IT, O’Neill TW, et al. Age-associated changes in hypothalamic-pituitary-testicular function in middle-aged and older men are modified by weight change and lifestyle factors: longitudinal results from the European Male Ageing Study. Eur J Endocrinol. 2013;168(3):445-455.
- Caldas AD, Porto AL, Motta LD, Casulari LA. Relationship between insulin and hypogonadism in men with metabolic syndrome. Arq Bras Endocrinol Metabol. 2009;53(8):1005-1011.
- Laaksonen DE, Niskanen L, Punnonen K, et al. The metabolic syndrome and smoking in relation to hypogonadism in middle-aged men: a prospective cohort study. J Clin Endocrinol Metab. 2005;90(2):712-719.
- Singh SK, Goyal R, Pratyush DD. Is hypoandrogenemia a component of metabolic syndrome in males? Exp Clin Endocrinol Diabetes. 2011;119(1):30-35.
- Biswas M, Hampton D, Newcombe RG, Rees DA. Total and free testosterone concentrations are strongly influenced by age and central obesity in men with type 1 and type 2 diabetes but correlate weakly with symptoms of androgen deficiency and diabetes-related quality of life. Clin Endocrinol (Oxf). 2012;76(5):665-673.
- Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract. 2006;60(7):762-769.
- Rezvani MR, Saadatjou SA, Sorouri S, Hassanpour Fard M. Comparison of serum free testosterone, luteinising hormone and follicle stimulating hormone levels in diabetics and non-diabetics men- a case-control study. J Res Health Sci. 2012;12(2):98-100.
- Molina-Vega M, Asenjo-Plaza M, García-Ruiz MC, et al. Cross-Sectional, Primary Care-Based Study of the Prevalence of Hypoandrogenemia in Nondiabetic Young Men with Obesity. Obesity (Silver Spring). 2019;27(10):1584-1590.
- Pellitero S, Olaizola I, Alastrue A, et al. Hypogonadotropic hypogonadism in morbidly obese males is reversed after bariatric surgery. Obes Surg. 2012;22(12):1835-1842.
- Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Available at https://pro.aace.com/disease-state-resources/nutrition-and-obesity/clinical-practice-guidelines/comprehensive-clinical (accessed July 2022) Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2016;22 Suppl 3:1-203.
- Dhindsa S, Miller MG, McWhirter CL, et al. Testosterone concentrations in diabetic and nondiabetic obese men. Diabetes Care. 2010;33(6):1186-1192.
- Cloostermans L, Wendel-Vos W, Doornbos G, et al. Independent and combined effects of physical activity and body mass index on the development of Type 2 Diabetes - a metaanalysis of 9 prospective cohort studies. The international journal of behavioural nutrition and physical activity. 2015;12:147.
- Hackett G, Kirby M, Wylie K, et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men-2017. The journal of sexual medicine. 2018;15(4):430-457.
- European Association of Urology. 2020 EAU Guidelines on Sexual and Reproductive Health. Available at https://uroweb.org/guideline/sexual-and-reproductive-health (accessed May 19, 2020).