Testosterone: Why it’s So Much More Than Sex and Six Packs

Article | Dr Jeff Foster, GP and Men's Health Specialist

Everyone has heard of testosterone, and most of us have a pretty good idea of what it does.

Testosterone is ‘The’ male hormone and is responsible for the majority of secondary sexual characteristics that differentiate men from women.

Testosterone gives men deeper voices, stimulates beard growth, and increases muscle mass and sexual desire, as well as all the other classic physical traits we associate with being male. However, it is this widespread understanding of the outward effects of testosterone on the human body that has, in part, led to it losing credibility and relevance in modern medicine.

In addition to its effects on our external physiology, testosterone is also responsible for a range of unseen metabolic, biochemical and neurological changes.

Testosterone affects blood pressure, lipid profiles, insulin sensitivity, bone density, cognition, mood and a range of other aspects of health and wellbeing. Therefore, while testosterone is of course a major contributor to muscle growth and sexual function, its true purpose, and consequently our understanding of its role in overall health, has been over distorted and misrepresented by the health and fitness industry, and is now, perhaps, underappreciated by the medical profession.

Many men will lead long and happy lives without ever knowing they had suboptimal testosterone levels

I have lost count of the number of adverts for over-the-counter supplements that claim to ‘boost’ testosterone, and diets that will allegedly increase its production; as if by simply eating more raisins (this is genuinely one food that has claims to increase testosterone production), our hormone levels will reach Hulk-like proportions.

The biggest problem with the fitness industry is that it plays on the insecurities and desperation that many men experience in wanting to get fitter, stronger, or look better. We all start to feel less energetic as we get older, and it would be great if our poor diets, hectic lifestyles, lack of free time, and little exercise, could be compensated for by taking a fenugreek pill each morning. But, in reality, this of course never works.

So how do you know if you might be suffering with low testosterone? In many aspects, the symptoms of testosterone deficiency (TD), match those of menopause in women; with early symptoms including fatigue, decreased mental acuity, altered body shape, and lack of sex drive.

As testosterone levels continue to decline, symptoms progress to a loss of morning erections, erectile dysfunction, depression and irritability, cognitive impairment (patients often describe this as brain fog), night sweats, loss of muscle mass and increases in body fat. But, in addition to the physical symptoms we see in TD, men also start to suffer metabolic problems such as changes in cholesterol levels, diabetes risk, blood pressure, osteoporosis, and the overall risk in morbidity and mortality.

To complicate matters, while some men with TD may suffer all of the symptoms listed above, not all men with low testosterone become symptomatic and, more importantly, not all men with low testosterone require treatment.

TD affects men in different ways, and a drop in testosterone production by a certain percentage does not automatically result in the same symptoms occurring in all men.

Many men will lead long and happy lives without ever knowing they had suboptimal testosterone levels. This uncertainty of age of onset, range of symptoms, and variability in symptom severity can make diagnosing clinical TD particularly challenging.

In contrast to men, every woman will go through menopause and, although premature ovarian failure can occur at any age (and we should always be mindful of this), the average age of menopause in the UK is still around 51.

This means that for most women, we are able to predict roughly when menopausal symptoms might become significant (although, again, this is not always the case). When men are most likely to become symptomatic with low testosterone is less clear.

Testosterone levels continue to rise naturally until the age of 30, where they then begin to decline by about 1% a year. The rate of decline can be lessened, in part, by adhering to a healthy lifestyle, taking regular exercise, eating well, minimising stress, having a good sleep pattern, and avoiding obesity.

However, multiple external factors can impact the hypo-pituitarygonadal (HPG) axis at any level, and can result in useable testosterone levels declining even more quickly.

The more common conditions that affect testosterone production are listed in Table 1.

So, in addition to not having a clear age of onset, early symptoms often being non-specific, and individual variations in natural testosterone production, we also have to be mindful of the wide range of conditions that can adversely impact on the HPG axis. But the main obstacle to successfully finding men with TD is none of the factors already discussed.

The biggest problem in diagnosing men with TD is actually due to established societal and cultural behaviour. Men still tend to be a population group who generally avoid seeing doctors, and often pass symptoms off as ‘working too hard’, or ‘just normal for age’.

Afterall, surely you should not be able to do at 40 what you did at 20, sexual desire must be less, and it is always harder to stay fit as we get older. This behaviour leads many men to avoid seeing their doctor until their symptoms become severe.

Frustratingly, for the vast majority of men, diagnosis and treatment of TD is relatively straightforward. Patients simply need to present with symptoms of low testosterone combined with two morning samples of blood testosterone (or free testosterone), below the British Society of Sexual Health Guidelines of 12nmol/l for total testosterone (or a free testosterone of <0.225nmol/l).

If a patient has no reversible contributing factors that are resulting in their low testosterone (such as obesity, specific medicines, or lifestyle problems), and their safety markers are normal, treatment is with testosterone replacement therapy (TRT).

In the UK, this is either with a topical preparation, or an injection. In most cases, TRT is safe, easy to monitor, and highly effective.

The key is finding the right patient, but we can only do so if we stop associating testosterone with six packs and little blue pills.

Overall, TD is a condition that is likely to have a much higher prevalence than is currently diagnosed. Not all men with TD will have symptoms, and not all men with low testosterone need TRT, but we are only going to improve the quality of life for men and improve their overall mortality and morbidity risk if we start thinking more about this condition and then test for it

Dr Jeff Foster

GP and Men’s Health Specialist

Jeff is one of the founders of H3 Health (a national Men’s and Women’s Health Company).

He is passionate about spreading awareness of men’s health topics, whether by lecturing, writing articles, creating videos and infographics, and of course, seeing patients within the NHS and at his private practice.

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