Substitution therapy for low testosterone levels is becoming increasingly popular. However, when there is actually hypognadism that requires treatment is not so easy to determine.
Low testosterone levels are common among men of a certain age. the Baltimore Longitudinal Study of Aging came to the conclusion that in the age group of 50 to 59 year olds, 10% have a formally reduced total testosterone level. The proportion increases with age: Among the 60 to 69-year-olds it is already 20% and over 50% of men over the age of 80 have testosterone levels below the normal range.
There are a number of explanations for this: On the one hand, it falls Testosterone purely due to age by approx. 1-2% every year; on the other hand, there are widespread comorbidities that lead to decreased testosterone levels. In the event of an illness-related hormone deficiency, substitution therapy is appropriate to bring the values back into the normal range. In the case of age-related decline, their use will certainly be controversial. Worldwide, the number of testosterone substitution prescriptions has increased over the past several years increased significantly.
But when does a patient really have a deficiency that requires treatment? Clarifying this question is not as simple as one might think, explained Prof. Stephan Petersenn at the joint press conference of the German Society for Endocrinology (DGE) and the German Diabetes Society (DDG). “If they get the word Testosteronmangel On its own, you might think you just need to measure testosterone in your blood and you’ve got the diagnosis – but that’s difficult.”
Measure testosterone, but correctly!
The problem starts with the correct measurement. According to Petersenn, the testosterone level is strongly dependent on the time of day; towards the afternoon a decrease of around 25% can be observed. A 25% decrease in value also occurs after eating. It is therefore essential to measure in the morning and on an empty stomach – and more than once. Testosterone levels are also subject to significant day-to-day variability, so it takes at least two independent measurements to determine if the level is actually low. This should be known in itself, but Petersenn says from his own experience in practice: “This is a common problem. […] When we check the values, we find in a third of the patients that the diagnosis cannot be confirmed solely by measuring the correct time of day.”
The next difficulty: interpreting correctly. The physiologically active, free hormone accounts for only 0.5-3% of the total testosterone level, the largest part is known to be in the transport proteins Albumin and SHBG (Sex Hormone Binding Globulin) bound. Accordingly, the testosterone must not be interpreted alone – SHBG must also be measured in order to be able to estimate the free testosterone level in relation to it. If the free testosterone is in the normal range despite the reduced total testosterone, there is no need for hormone replacement, explains Petersenn.
Measurement only required for specific symptoms
However, Petersenn emphasizes: “We shouldn’t just measure the testosterone level, we also have to perceive the corresponding symptoms.” This is not about unspecific symptoms such as tiredness and reduced strength, which are often taken as a reason to doubt the sufficient testosterone level. Since they can occur with a variety of other diseases and as a result of stress, they do not help with the diagnosis. More meaningful are the noticeable reduction in libido, erectile dysfunction and the decrease in morning erections – these three symptoms are much more specific for Hypogonadism emphasizes Petersen. If these clinical symptoms are present, the testosterone level should be measured.
Using this definition of testosterone deficiency – the presence of clinical symptoms plus a correctly determined deficiency of free testosterone – reduces the prevalence and the need for treatment significantly. Petersenn speaks of 0.6% of the 50 to 59 year olds, 3.2% of the 60 to 69 year olds and around 5% of the over 70 year olds who actually need a substitution. The therapy makes sense because the lack of testosterone not only affects libido, psyche and weight; low levels of the hormone also favor the development of a osteoporosis and pronounced defects often go with one, according to Petersenn Anämie along.
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Risk factors for obesity and diabetes
Doctors should keep an eye out for possible hypogonadism, especially in diabetics and obese patients. In about 25% of patients with Typ-2-Diabetes I have a testosterone deficiency with clinical symptoms for which substitution should be initiated. Although the primary purpose of treatment here is to improve clinical symptoms, it can be said that testosterone substitution can improve both BMI and glycemic control. It does not always have to be a substitution to bring the testosterone level up to scratch: a lifestyle change can already lead to improvements. “If [die Patienten] improve their hyperglycemia situation and lose weight, then their testosterone levels will rise again.”
With such a high prevalence among male diabetics, should the testosterone level be determined automatically so that nothing is overlooked? No, Petersenn thinks. “However, we would advocate actively asking about the specific symptoms of a deficiency.”
Finally, Petersenn also spoke about the possible side effects of testosterone substitution. When it comes to compensating for a correctly diagnosed deficiency, there are hardly any side effects to be expected – after all, only the target state is restored. When it comes to whether testosterone should be given to diabetics without a deficiency in order to improve the development of the disease (or testosterone substitution in old age), the associated risks must be considered. One problem, for example, is an increase in hematocrit, which is associated with an increased risk of circulatory disorders and stroke. The liver values are also increased by additional testosterone administration.
Image source: Erik Mclean, unsplash