Testosterone Deficiency
Testosterone Replacement

Testosterone Deficiency

The disease state of low testosterone is referred to by many different names such as hypogonadism, andropause and androgen deficiency in the aging male (A.D.A.M.). These terms are oftentimes used interchangeably and create confusion even amongst healthcare professionals. All of these terms refer to a condition of low testosterone that is associated with other symptoms. Some of the signs and symptoms include a decreased sex drive, fatigue, erectile dysfunction, falling asleep after dinner, memory and concentrating difficulties, bone density loss and diminished work performance. Oftentimes these symptoms are overlooked or attributed to some other condition such as normal ageing. Effective therapy for testosterone deficiency exists.

Why is my testosterone level low?

It is a well known fact that a man’s testosterone level begins to decline as early as the age of thirty (30). In fact, large longitudinal population studies have shown that a man’s tetsosterone decreases by approximately 1% per year after the age of 30. The incidence of low testosterone has been reported to be around 40% in men over the age of 45. Similar to when a woman goes through menopause, men go through andropause but at a much slower rate. Consequently, many of the symptoms associated with this condition can be insidious.

What are some other conditions associated with Hypogonadism?

Certain common conditions are frequently associated with low testosterone. The following table lists some of these conditions.

Ageing Metabolic Syndrome COPD/Sleep Apnea
Obesity Kidney Disease Stress
Diabetes Mellitus HIV/AIDS Chronic Infections
Chronic Opiod Use Sickle Cell Disease Medications


Alerting your physician to any of the symptoms asssociated with low testosterone is important. A health inventory questionnaire called the A.D.A.M questionnaire was designed to identify patients who potentially might have low testosterone levels. If you answer yes to any three questions or to any single sexual question, there is a strong possibilty that you have a low testosterone level. Your physician will order confirmatory lab tests prior to commencing any therapy.

What types of treatment options are available for men with low testosterone levels?

There are a variety of treatment options available for the man with low testosterone levels. Currently, there are oral, buccal, transdermal gels, patches, intramuscular injections and subcutaneous pellets available to treat hypogonadism. Each form of therapy has specific advantages and disadvantages associated with it. You can discuss with your physician which form of therapy is right for you.

One of the long-term treatment options is the insertion of subcutaneous pellets called Testopel®.  This is done with a short 3 minute procedure in the office every 4 months for most patients.  Current Medicare guidelines allow us to only place enough Testopel pellets to last 3 months in Medicare patients.  The following is a video of Dr Karpman doing the Testopel procedure.

What are the risks of testosterone replacement therapy?

In general, testosterone replacement therapy is very safe, after all, nobody ever tells a young man with a healthy testosterone level that he is in any danger and it should be reduced to a lower level. Why should any man be told that testosterone replacement therapy (TRT) is dangerous for him when his counterpart of equal age, but normal testosterone level, is not told that he might be in danger with such a high testosterone level?  People oftentimes confuse the difference between replacing testosterone in the body to return it to normal physiologic levels with taking testosterone to achieve “super-physiologic” levels for performance enhancement. These are clearly two different situations.

Recently, there has been a new concern over possible cardiovascular complications such as heart attack, stroke and death with TRT based on 2 severly limited and flawed studies published in the medical literature.  First, these two studies were retrospective database studies and not prospective randomized controlled studies as one would expect of such headline-grabbing results we have seen in the popular press.  Both studies had significant limitations in the their ability to reach the conclusions they made in their papers.  The Vigen et al paper had two revisions after the paper was initially published because of errors and omissions. The biggest error was the conclusion that TRT increased the “absolute rate” of these adverse events from 19.9% in the untreated group vs 25.7% in the testosterone treated group.  This is not true.  The absolute rate was actually 21.2% in the untreated group vs 10.1% in the testosterone treated group.  Their conclusion was only obtainable after doing highly complex and not validated statistical methodology that increased the the percentage of events in the testosterone treated group 3-fold!  This paper now becomes an example of how misleading statistics can make any outcome seem even when the “actual” data reflects a different conclusion.  This highly talked about paper was also flawed by excluding men who were not on TRT and had an adverse event, but were subsequently started on TRT.  These men should be included in the untreated group.  Finally, they accidentally included 10% of the dataset that were women in an all male study.  Because of this, a group of international testosterone replacement experts started the Androgen Study Group to educate the public and combat misinformation in the press.

The other concerns about testosterone replacement therapy are related to prostate health and the development of prostate cancer. Some hypogonadal men might notice a slight worsening of their urinary symptoms or increase in their PSA. This occurs because the prostate and PSA are directly controlled by testosterone. Replacing testosterone into the normal range only increases urinary symptoms and PSA into the range where they would be if the testosterone level was not low in the first place. Men with testosterone levels in the normal range (300-1000 ng/dl) are at no greater risk of developing prostate cancer than their hypogonadal counterparts. Hypogonadism is not only NOT protective against prostate cancer, there is some evidence to suggest that hypogonadal men might develop a more aggressive form of prostate cancer. The risks of osteoporosis and fractures are reduced in men on testosterone replacement therapy.