In my practice, I often see men in their 30s with constantly low energy and a poor sex drive, wondering if there's something wrong with them. These group of men usually attribute their symptoms to a stressful work environment.
Instead, what I commonly find is that they have low testosterone levels.
1. What is testosterone?
Testosterone is a male hormone that's created by your testicles (gonads). It has many important functions, including bone growth and maturation, as well as muscle bulk enhancement.
In older adults, it has an important effect on sexual health and function.
2. Do you have low testosterone?
All men can be affected by a low testosterone state, otherwise known as testosterone deficiency syndrome (TDS). It's useful for you to complete the ADAM Questionnaire if you think that you might have low testosterone.
Some of the symptoms that would suggest TDS, as outlined in the questionnaire include the following:
- Poor focus and low exercise endurance - This is a common presentation that makes me suspect a patient has TDS.
- Low sex drive – Testosterone plays a pivotal role in men’s sex drive.
- Erectile dysfunction – Testosterone is needed for healthy erections.
- Mood swings – Studies have shown that low testosterone leads to poor mood and increased irritability.
- Body mass changes – A normal testosterone helps to maintain adequate muscle mass. Men with low testosterone may experience increase in body fat, or in some cases develop gynaecomastia (enlarged breast tissue).
3. How is testosterone checked?
Testosterone levels are checked in the morning, as the highest concentration is usually found between 8 - 10 am.
Besides checking testosterone, when I suspect that someone has low testosterone, I'll usually also check Luteinising Hormone (LH) and Follicle Stimulating Hormone (FSH) levels.
LH and FSH are produced in the brain, and regulate the amount of testosterone produced. Performing these 2 additional tests helps me to differentiate a “brain vs balls” cause for low testosterone.
The 2 most commonly used tests to check for testosterone levels in Singapore are:
- Total Testosterone (about $30)
- Free Testosterone ($100 - $120)
My personal preference would be to perform a Total Testosterone assay.
4. How is testosterone deficiency syndrome treated?
When it comes to replacing testosterone, I advise my patients to consider the following options carefully, while taking into account their aversion to pain and needles:
- Clomiphene - this is a tablet that helps to stimulate your body's own (endogenous) testosterone production. It may increase your oestradiol (female hormone) level, and so should only be considered after you've completed your family. The monthly cost is about $60.
- Oral testosterone pills – Some urologists use this, but there's an increased risk of liver tumours, which makes it a less attractive option. I don’t usually use this in my practice.
- Topical testosterone creams/gel – I highly recommend this to my younger patients who are squeamish about needles and pain. This is a convenient replacement method that's done once a day. The price of this therapy can range from $100 - $200 a month.
- Injectable testosterone – I see a great deal of patients who come back regularly for their testosterone jabs. Injectable testosterone comes in different types, with variable longevity. Nebido (testosterone undecanoate) has a long effect of 10 - 12 weeks, which means an injection every 3 months. The approximate monthly cost is $380 - $400.
In the local setting, options 3 and 4 are much more common.
5. What can you expect after testosterone replacement?
My patients tend to notice that their energy levels increase first, followed by an improvement in sexual libido after the first couple of weeks. Erectile dysfunction improvement is seen at least 6 - 8 weeks after.
Do note that there are also some adverse effects of testosterone replacement to be aware of. These include:
- Worsening hair loss, especially in patients with existing male pattern hair-loss.
- Increased acne and skin oiliness.
- Reduced sperm count – if the frequency or dosage of testosterone replacement isn't well titrated, there can be a reduction of up to 97% of sperm count. Fertility counselling or family planning should be carried out prior to starting treatment.
The most important thing to bear in mind is that replacing testosterone WILL adversely affect your sperm count and fertility. Do consider this factor, especially if you haven't completed your family!
Dr Winston Lee manages South Bridge Aesthetics Clinic, and has a special interest in men's health. He enjoys the occasional cuppa, and de-stresses through gardening.