A Disservice to Men
Your grandfather probably had higher testosterone than you. As a matter of fact, average testosterone levels in Men have been significantly declining over the past several decades.
The reason for this is multi-factorial and not entirely understood; however, what IS understood, is that:
Low testosterone is linked to cardiovascular disease, diabetes, obesity, depression, and sexual dysfunction. Perceived quality of life, mood, and even day-to-day behavior are all heavily influenced by testosterone.
The good news is, studies on testosterone replacement therapy (TRT) suggest it is safe, well-tolerated, and is associated with significant benefits in sexual function, quality of life, mental clarity, cardiovascular health, glycemic control, anemia, bone density, and lean muscle gain. New research even shows an association between patients who take TRT and metformin and a reduction in prostate and colorectal cancer.
Now, you might be wondering, if testosterone is so important to a man’s health, and low testosterone so prevalent in our society, AND there exists a safe and effective treatment for low testosterone, why is the medical community so reluctant to discuss, assess, and treat it?
Again … it’s multifactorial. Part of the reasoning involves nuances and complexities in making the diagnosis. For example, checking testosterone is not as straight forward as is testing cholesterol or blood sugar. Testosterone levels in healthy men fluctuate throughout the day, different labs use different testing parameters, and men frequently have an individualized “sweet spot.” For example, some men may feel great at around 550 ng/dL total testosterone while others become symptomatic.
To further complicate things, even if a man has “normal” total testosterone, his “free” bioavailable testosterone can be low. Having a suboptimal free testosterone level, regardless of what total testosterone is, is associated with “low-testosterone symptoms” and warrants treatment.
Interestingly, if someone has symptoms of anxiety, regardless of the underlying reason, it’s very easy to prescribe them a Selective Serotonin Reuptake Inhibitor (SSRI). Do providers check serotonin levels before prescribing it? No.
Although these drugs benefit many, they are not for everyone and come with side effects to include weight gain and sexual dysfunction. So, if a Man complains of anxiety, which could be due to suboptimal testosterone levels, now he’s on an SSRI which only make symptoms of low testosterone worse (weight gain and sexual dysfunction).
Unfortunately, it isn’t as “cost-effective” for insurers to pay for hormone labs as it is to pay for an antidepressant prescription. Men are frequently put on blood pressure, cholesterol, diabetes, and anxiety drugs before ever even having their testosterone evaluated.
Even when insurers do cover testosterone labs, it’s usually only a total testosterone, which is not enough information by itself.
Most guidelines recommend to only order a free testosterone if total testosterone is confirmed to be low first. But did you know you can have a low free testosterone (which is what your body uses) and a “normal” total testosterone? This approach is problematic and puts men at risk for being misdiagnosed and mismanaged.
Another roadblock men face is due to results from the “Testosterone Trial” in older men study that has since been discredited due to several limitations. The study enrolled 209 men, who on average, were 74 years old with a high prevalence of preexisting cardiovascular and metabolic health conditions. The study was stopped early because some of these older men with heart problems were having heart problems … 🤦♂️
Additionally, a testosterone gel was used instead of injectable TRT. Testosterone gel is not recommended as it is associated with a higher prevalence of side effects due to the unnatural absorption through your skin. Although discredited, this study is the basis of many of the restrictions on the therapeutic indications for TRT providers face today and is why there is an FDA warning for TRT. Even though more recent and reputable studies demonstrate cardiac protective effects of testosterone replacement when dosed and monitored appropriately.
This is nothing against primary care providers or insurers; however, it’s one of many critical problems with our medical system today. Fortunately, with emerging literature on the benefits of TRT, I expect it will become more accessible to those who need it. Until then, you have us.
If you want to get labs done, I order the following at a minimum before initiating testosterone replacement therapy for my patients: Total & Free Testosterone (LC/MS/MS), Sex-Hormone Binding Globulin, Luteinizing Hormone, Follicle Stimulating Hormone, Estradiol-LCMS (LCMS is more sensitive and is the only type a man should have ordered), Complete Blood Count w/ Diff, Complete Metabolic Panel (liver, kidney, and electrolytes), Hemoglobin A1c (to assess for underlying diabetes), lipids, PSA, TSH (thyroid function), and Vitamin D.
If you are in Florida and would like a lab order put in, I can either send a phlebotomist to your home or you can visit a lab.
