Replacement Therapy
To assess whether you may benefit from testosterone replacement therapy, you will need an evaluation that includes completing a comprehensive medical history, a physical examination, and laboratory checks to get a global understanding of your testosterone capacity.
A comprehensive assessment of symptoms is required to determine if you have symptoms related to low testosterone. The most frequent symptoms of low testosterone in men include reduced sex drive, difficulty with erections, and chronic fatigue. A detailed history will unveil these undesirable symptoms affecting men with low testosterone. Clients will often describe relationship difficulties because they have lost their intimacy. Male clients can be questioned regarding their ability to achieve an erection or to maintain an erection during intercourse.
Another often more subtle symptom involves feeling tired or being physically sluggish. Chronic fatigue is appreciated by many patients who have observed weight gain. Weight gain, unfortunately, can occur as part of the normal aging process and thus camouflage the effects of low testosterone. Weight gain results from an increase in fatty tissues even though there is a simultaneous loss of muscle mass. Loss of muscle mass further compounds feelings of sluggishness resulting from becoming overweight.
Physical examination is necessary to confirm physical signs that can occur with low testosterone, including loss of body and facial hair, loss in muscle mass, and increased belly girth. Testosterone metabolite DHT directly affects the growth of hair cells and has been shown to affect both body and facial hair adversely. Loss of both body and facial hair is best appreciated in men. For women, there is a paradoxical loss of hair on their heads! A more concerning physical finding involves the loss of muscle bulk. The loss of muscle volume results in changes in your body physiology and symptoms of weakness. Although aging will result in routine muscle loss, the low testosterone that occurs with aging will be exaggerated by low testosterone.
Finally, clients will universally observe weight gain even if they have not drastically altered their diet or lifestyle. This is because low testosterone will directly increase the proliferation of fat cells in the gut, called visceral fat. This is because visceral fat cells are most sensitive to hormonal changes in the body. An increase in visceral fat is physically undesirable as it results in a protruding belly and is also detrimental to your health.
The final workup for low testosterone involves a comprehensive laboratory workup. Laboratory findings are necessary to document low testosterone levels and determine whether other hormones may be abnormal. This is because hormones are intimately interrelated and affect each other’s values. Specifically, the thyroid hormone affects the pituitary gland’s growth hormone, the adrenal gland’s cortisol and DHEA production, and all sex hormones, including estrogens, progesterone, and testosterone. Any thyroid hormone abnormalities require correction before considering testosterone replacement therapy. Initial laboratory workup should include the following:
Total Testosterone
Total testosterone measures the total testosterone calculated by testosterone, that is, bound sex hormone binding globulin, SHBG, and free testosterone. Normal values for total testosterone fall in the range of 300 to 1000 ng/DL. This is a large range as it provides the normal range for clients ranging from 18 to elderly males. Naturally, as we age, testosterone levels gradually decrease in value. Total testosterone measures your testosterone levels, but it may not provide a clear picture of active testosterone available for use by your body cells. If SHBG levels are high, then less testosterone may be functionally available.
Free Testosterone
Free testosterone is the active form of testosterone since it is not bound by proteins and is available testosterone. As such, free testosterone is a much more sensitive indicator of available testosterone. Free testosterone is helpful if SHBG levels are low, leading to a false total testosterone finding.
Estradiol
Estradiol is typically considered a female sex hormone, but it can significantly affect men. As a general rule, estradiol or estrogen is the counter hormone to testosterone. High estrogen levels can counter testosterone resulting in poor sexual function, erectile dysfunction, and overgrowth of breast tissue termed gynecomastia.
Sex Hormone Binding Globulin
Sex hormone binding globulin, or SHBG, measures a protein that binds the sex hormones, including testosterone, estrogen, and progesterone. When these hormones are bound to SHBG, they are considered inactive and thus not free to be used by the cells in your body. This is why, when measuring the hormone testosterone, the total and free levels must be evaluated as an initial gauge.
PSA
Prostate-specific antigen, or PSA, is a laboratory value used to screen for prostate cancer. High testosterone levels can make you vulnerable to prostate cancer progression. As a result, a high PSA level may be a contraindication to testosterone therapy. Normal upper limits for PSA in white males include 2.5ng/ml for 40 to 49 years old, 3.5 ng/ml for 50 -59 years old, 4.5ng/ml for 60 to 69 years old, and 6.5 ng/ml for 70 to 79 years old.
Free T3, Total T4
The thyroid gland produces two forms of thyroid hormone: triiodothyronine (T3) and thyroxine (T4). If you are low in your thyroid hormones, you may experience low testosterone, lack of energy, weight gain, and signs of depression. The importance of the thyroid can not be overstated but normalizing your thyroid hormones is paramount before altering your testosterone levels.
CMP
The complete metabolic panel, or CMP, is an important laboratory test that evaluates your metabolic and detoxification systems regarding your kidney and liver functionality. This test is an important laboratory finding since it establishes how quickly your body will metabolize any supplemented hormones, including testosterone. For example, how well your kidneys function, measured by your glomerular filtration rate (GFR), is critical to ensure safe testosterone dosing.
CBC
CBC values provide you insight into your immune function and blood levels. Specifically, your white blood count, WBC, and levels ensure that you don’t have an active infection before inserting your pellets. Moreover, your hemoglobin and Hb levels are important since testosterone can hypothetically elevate your Hb levels to unsafe levels. This is a test that should be repeated during the maintenance phase of Testosterone pellet therapy.