Male Hormone Replacement


Male Hormone Replacement Therapy

The average age of men in Singapore is projected to rise significantly over the next 25 years, with the greatest increase occurring in men > 65 years old.

As this happens, there will be a dramatic increase in age-related health problems too, including cancer, strokes, heart disease and hormone deficiency. Although the health risks associated with age-related hormonal decline in women, termed menopause, have been thoroughly addressed, it has now been shown that hormonal changes in the aging male are associated with significant health problems.

It is natural for men’s testosterone levels to decrease as they get older. Just as women lose their natural levels of Estrogen hormones as they go through menopause, so do men lose their naturally high levels of Testosterone hormone as they age.

Testosterone is required for:

• male sexual development
• reproductive function
• building muscle bulk
• maintaining healthy levels of red blood cells
• maintaining bone density

There is a progressive decline in testosterone production in men with age. These changes can be dramatic, such that 50% of men >60 years old have low levels of testosterone. Although the rate of decline varies widely, a general rule of thumb is that testosterone levels decrease about 1% yearly after age 50. Serum testosterone levels in men fall progressively from the third decade to the end of life, mainly due to a decline in the cells in the testis that make the hormone (Leydig cells). This decline may also be due to changes in hormones (GnRH, LH) and proteins (SHBG, albumin) that regulate testosterone production.


What are the symptoms of low T?

Regardless of your age, low T symptoms can include:
• erectile dysfunction, or problems developing or maintaining an erection
• other changes in your erections, such as fewer spontaneous erections
• decreased libido or sexual activity
• infertility
• rapid hair loss
• reduced muscle mass
• increased body fat
• enlarged breasts
• sleep disturbances
• persistent fatigue
• brain fog
• depression

Many of these symptoms can also be caused by other medical conditions or lifestyle factors. If you’re experiencing them, make an appointment with our doctors. They can help you identify the underlying cause and recommend a treatment plan.

What causes low T in young men?

Low T is less common among men under 30, but it can still occur. Contributing factors include:
• high cholesterol levels
• high blood pressure
• being overweight or obese
• drinking excessive amounts of alcohol
• using illegal drugs
• using anabolic steroids
• taking certain prescription medications such as steroids and opiates, especially in excess

Some cases of low T may be linked to other medical conditions, such as:
• hypothalamic or pituitary disease or tumors
• injuries, tumors, or other conditions affecting your testicles including inflammation related to childhood mumps
• diabetes, liver disease, or AIDS
• cancer treatments such as radiation and chemotherapy

Advantages of Testosterone Replacement Therapy

• Better Bones
In men with low testosterone levels, testosterone can improve bone mineral density and reduce bone fractures, an effect similar to that found in postmenopausal women on estrogen replacement. Importantly, hip fractures are 2-3 times as likely to kill an older man as a woman of the same age, and 40% of older male patients with hip fractures die within 1 year of the injury.

• Less Fat; more Muscle mass
Testosterone results in increases in lean body mass, possibly strength and can decrease fat mass. By stimulating erythropoietin, testosterone increases blood counts. Testosterone is responsible for increased muscle mass. Leaner body mass helps control weight and increases energy. For men with low testosterone, studies show that treatment can decrease fat mass and increase muscle size and strength. Some men report a change in lean body mass but no increase in strength. It’s likely you will see the most benefits when you combine testosterone therapy with strength training and exercise.

• Better Sexual Health
Sexual function also improves with testosterone. Most studies agree that sexual drive is improved by testosterone. Penile erections may be improved with testosterone, but only in men with low testosterone levels. Important, isolated low testosterone is an unusual (6%) cause of erectile problems in older men as lower sex drive and age-related changes to the penis are far more common.

• Healthy heart and blood
A healthy heart pumps blood to the rest of the body, providing muscles and organs with the oxygen needed for peak performance. Testosterone helps red blood cell production through the bone marrow. Low testosterone levels are linked to a variety of cardiovascular risks.
Testosterone can help with preventing heart disease. Small studies in the early 2000s found that men with heart disease who underwent testosterone therapy saw only slight improvements. Some were able to increase their walking distance by 33 percent. Another study found that hormone therapy only widened healthy arteries but had no effect on angina pain.

A more recent, larger study of 83,000 men found that men whose testosterone levels returned to normal were 24 percent less likely to have a heart attack and 36 percent less likely to experience a stroke.

• Better verbal memory, spatial abilities, or mathematical reasoning
Research shows that men with higher ratios of total testosterone have a reduced incidence of Alzheimer’s disease. There is also evidence for a strong correlation between testosterone and thinking abilities such as verbal memory and faster processing speed. Testosterone treatment for men 34 to 70 years old has shown an improvement in spatial memory.

• Improved mood
Lower testosterone levels are associated with poorer quality of life. Some of the symptoms of low testosterone levels include depression, fatigue, and irritability. But some research shows that this may only be for men with hypogonadism. Men whose bodies follow the normal decrease of testosterone over time didn’t show an increase for depression.

Laboratory Tests

Because testosterone is found in several forms in the blood, there is debate as to what test is best to diagnose testosterone deficiency. In general, a total testosterone is ordered first.


National guidelines suggest that a testosterone level below 300 ng/dL is suspicious for being low, but obviously this will vary among men. Evidence of a prior testosterone level that is much higher than a current level might warrant treatment even if the current level is > 300ng/dL.

Types of hormone therapy for men

Several options are available. These include:
• Intramuscular testosterone injections: Your doctor will inject these into the muscles of your buttocks every two to three weeks.
• Testosterone patches: You apply these each day to your back, arms, buttocks, or abdomen. Be sure to rotate the application sites.
• Topical testosterone gel: You apply this each day to your shoulders, arms, or abdomen.


Monitoring during Testosterone replacement therapy

Testosterone replacement is generally considered a long term therapy and patients need to be monitored regularly.Prior to starting treatment, a digital rectal examination and serum PSA are important. A baseline general screen and hormone profile blood test must be ordered.

Within a month or two after treatment is started, symptoms and testosterone levels should be assessed. During the first year of therapy, patients should be followed regularly to assess clinical response.

After the first year, patients who are stable may be followed annually. Annual evaluations should include testosterone, hemoglobin, liver function tests, lipid profile and PSA tests. Bone density and psychological evaluations can be done depending on the original reasons for treatment.


Risks of testosterone therapy

Side effects are a primary drawback of hormone therapy with testosterone. While some of the side effects are relatively minor, others are more serious.

Minor potential side effects of hormone therapy with testosterone include:
• fluid retention
• acne
• increased urination

More severe potential side effects include:
• breast enlargement
• decreased testicle size
• worsening of existing sleep apnea
• increased cholesterol levels
• decreased sperm count
• infertility
• increased number of red blood cells

An increased number of red blood cells can cause:
• muscle pain
• high blood pressure
• blurry vision
• chest pain
• blood clots in your blood vessels