True North Metabolic
Low Testosterone &
Testosterone Replacement Therapy (TRT)
Patients who may have low testosterone (known as hypogonadism) can exhibit symptoms such as fatigue, low libido, erectile dysfunction, mood changes, feeling unwell and other symptoms.
Low testosterone is diagnosed with blood tests and may require a second confirmation test depending on the initial lab result.
Once the diagnosis is made, underlying causes need to be ruled out and then treatment can begin.
Causes of Low Testosterone
There are numerous causes of low testosterone. We aim to find out if the cause is primary hypogonadism or secondary hypogonadism where another disease process is causing the low testosterone.
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Examples of primary hypogonadism include:
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Klinefelter syndrome
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LH/FSH receptor mutations
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Chronic organ disease such as liver disease
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Certain medications
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HIV
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Mumps
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Certain autoimmune diseases
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Hemochromatosis
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Cryptorchidism
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Examples of secondary hypogonadism include:
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Chronic opioid use
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Hyperprolactinemia
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Diabetes
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Corticosteroid use
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Infiltrative disease
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Certain tumors
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Kallman syndrome
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Testing and Treatment
Diagnosing low testosterone requires blood tests that include the total and free testosterone levels. Once the diagnosis is made, then the next step is to make sure there isn't an underlying disease process. While patients with low testosterone do require replacement therapy, it is important to make sure there isn't anything else being missed.
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Additional testing includes:
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LH and FSH to help determine primary versus secondary hypogonadism
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Ferritin and serum iron studies to rule out hemochromatosis
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Prolactin levels
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Targeted testing based on your symptoms and other possible causes
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The laboratory evaluation is generally quite extensive and always includes "routine" comprehensive blood work. Certain patients may also require an MRI or ultrasound depending on what the laboratory evaluation and history and exam show.
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Once the decision is made to start treatment, there are various therapies available. Injectable testosterone is a common modality of treatment. We generally aim for more frequent dosing to ensure stability of the levels. For men who absolutely cannot inject, there are topical creams available as alternatives. In certain cases where immediate fertility is a concern, discussions can be had about non-testosterone agents.
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After treatment starts, there will be the need to do periodic monitoring. Monitoring lab tests include:
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hemoglobin/hematocrit
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total and free testosterone
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LH and FSH
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PSA (depending on age)
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lipid panel & apoB
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other targeted testing
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These tests are done at approximate 6-8 weeks intervals after treatment initiation and subsequently become spaced out as time goes on. The goal is to ensure your serum testosterone levels are in an appropriate range while watching out for complications.
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