Testosterone is an essential hormone that regulates many processes in the male body. Although popular culture portrays it as a “hulk serum” that causes men to go on a violent “roid rage”, it is in fact it is often a low level of testosterone that affects the overall wellbeing of a man leading some to having drastic mood swings, poor sleep and poor quality erections. Other symptoms of low Testosterone include loss of muscle strength, poor concentration, difficulty losing weight or maintaining a current weight. Of course, aside from such observable symptoms, low Testosterone also has more insidious consequences like increasing the risk of Diabetes, Osteoporosis and Prostate Cancer.
What exactly is Testosterone? And why is it so important?
Testosterone is literally the hormone that makes a man a man. It is produced predominantly in the testicles. Puberty is the time where the effects of testosterone are the most prominent where it drives development of androgenic or male features such as square jaws, deepening of the voice, growing a beard and body hair, broadening of the skeletal bones and overall muscle development. From a sexual function perspective, testosterone enhances sperm maturation, increases the male libido and is associated with better erection quality. Of course, Testosterone is not only a “sex hormone”. Much like HGH (Human Growth Hormone), it is vital for other bodily functions such as maintaining muscle mass and strength, maintaining a low body fat, maintaining strong bones and aiding in control of blood sugar.
Testosterone naturally decreases with age. However, chronic diseases such as obesity and diabetes can cause Testosterone levels to drop faster than expected.
What are the symptoms of low Testosterone?
The symptoms that may prompt you to get your testosterone levels tested include:
- Easy fatigability, low energy
- Brain fog
- Weight gain or difficulty in losing weight
- Low libido (poor sex drive)
- Poor erections
- Mood swings or even depression
- Loss of muscle mass and strength
- Poor sleep
- Male Breasts (Gynaecomastia)
How do I know if my Testosterone is low or not?
Start with evaluating your symptoms. That said you should always see a Doctor. Low Testosterone share many symptoms with other illnesses and diseases so your Doctor will have to analyze your case and determine the exact diagnosis.
There are several verified questionnaires to quantify their symptoms and see how closely that correlates to Testosterone Deficiency:
- Sexual Health Inventory for Men (SHIM)
- Androgen Deficiency in Aging Male (ADAM)
- Aging Male Symptom Score (AMS)
A quick scenario that I like to ask my patients to consider when asking about symptoms of testosterone deficiency is as follows:
If your partner gave you a list of 10 things to get from the mini-mart that is 1km away, would you:
- Forget most of the 10 things if you did not write them down
- Be out of breath after walking to the mini-mart
- Get irritated easily when your partner suggests you write the 10 things down next time
If your answer to those questions were Yes and if you find that such situations are becoming more common in recent times, it is probably best to start the conversation with your doctor about Testosterone Deficiency.
Is there a way to test for Testosterone levels in my body?
Determining Testosterone level is done with a simple blood test. There are 2 numbers you want to be looking out for:
- Total Testosterone
- Free Testosterone
It is generally agreed that a Total Testosterone level of < 8 nmol/L (231 ng/dl) requires active treatment. While treatment can be considered for patients with a Total Testosterone of between 8 to 12 nmol/L (231 to 346 ng/dl) depending on their symptoms. However, these numbers are just guidelines and the final decision still lies with your Doctor. There have been studies out of Europe to show that patients will start to show symptoms of low Testosterone when their Total Testosterone level drops below 16 nmol/L (461 ng/dl). Also there is great inter-individual variation of Testosterone levels. In other words, I may feel perfectly fine with a Total Testosterone level of 12 nmol/L while you may have many symptoms at the same level.
Sometimes, the total Testosterone level is very healthy yet the patient has all the symptoms of low Testosterone. This could be due to his Free Testosterone being too low. Most of the Testosterone in our blood is actually bound to proteins. So if a person has too much of these special proteins called SHBG (Sex-Hormone Binding Globulins), his Total Testosterone could be healthy but his Free Testosterone is too low. Since the body only responds to Free Testosterone, this would result in the person suffering from many of the symptoms of low Testosterone despite having a normal Total Testosterone level.
The most accurate way to measure Free Testosterone is with a lab technique called Equilibrium Dialysis. This is a complex and costly technique so not many commercial labs do this. A cheap an accurate technique is to measure the Total Testosterone, SHBG and Albumin levels and calculate out the Free Testosterone. There are several free Testosterone Calculators available online.
The final important thing to note about your blood test is that testosterone levels do fluctuate through the day, hence the ideal time to test your testosterone levels is between 8 to 11 am.
What can I do to increase my Testosterone levels naturally?
If you are overweight or obese, get back to a healthy weight. There are numerous studies linking low Testosterone to obesity and consequently a natural increase in Testosterone once a person gets back to a healthy weight. Click here for my article on weight loss.
To be more precise, I should say reduce adiposity (fat) rather than reduce body weight per se. What you want is a better body composition. In other words, more lean muscle and less body fat. Of course, this could be an uphill struggle. Because a low Testosterone reduces the basal metabolic rate, reduces lean muscle mass and reduces drive, many patients with low Testosterone struggle with weight loss.
If the SHBG level is too high, lowering it can increase the level of Free Testosterone. This will help ameliorate most of the symptoms of Low Testosterone. Click here for my article on SHBG, Free Testosterone and natural methods for improving the values.
If the testicles are already damaged, there would be no way to naturally increase Testosterone production and the patient will be dependent on Testosterone Replacement Therapy. The testicles can be irreversibly damaged by infection, radiation, heat, trauma and surgery. The function of the testicles also naturally decrease with age.
Do Testosterone boosting supplements work?
There are many health supplements available that claim to boost Testosterone. Unfortunately, none of them have any strong scientific proof that they work. In fact, some of them may contain active pharmaceutical drugs and may be dangerous if consumed without appropriate advice.
The most famous aphrodisiac in this part of the world is Tongkat Ali (Eurycoma Longifolia). Studies in rats found that Tongkat Ali induced better erections and has aphrodisiac and pro-androgenic properties. However there are no studies to show an actual increase in Testosterone.
The other very popular Testosterone supplement is Tribulus (Tribulus Terrestris). In studies involving rats and rabbits, Tribulus did increase Testosterone and led to better erections. However one study in young men showed that it did not increase Testosterone levels.
Click here for my article on herbal aphrodisiacs.
What treatments are available for low Testosterone?
The goal in the treatment of Testosterone Deficiency is to replace the testosterone and provide relief from the symptoms. Prior to starting treatment, it is important that the diagnosis of Testosterone is established by a blood test and a consultation with your doctor.
Your doctor should advise you how best to achieve such levels and also outline a schedule for blood tests to check the levels. Most important of all, beyond the numbers, you should gauge if you are getting relief from the symptoms. Like my Professor used to tell me – treat the patient not the numbers!
Because obesity is a significant risk factor for testosterone deficiency, I do advise my patients to consider starting a weight management program. More often than not, many men find themselves in a vicious cycle when it comes to their weight and suffering from Testosterone Deficiency. The fatigue and low energy caused by Testosterone deficiency makes men less likely to want to exercise, however, the less they exercise, the more obese they become leading to a further decline in their testosterone. Therefore, losing weight can be a good first step in relieving the symptoms of a low testosterone.
Currently in Singapore, only the transdermal (Gel) and injectable formulations of Testosterone are available. Testosterone pills used to be available but they have been discontinued in 2021.
Testosterone Gel
Testosterone Gels are one of the most popular methods of Testosterone treatment. Currently in Singapore, only one brand Androgel is available. Androgel is a transdermal formulation of testosterone. It is an alcohol based gel which is applied once a day. It comes in convenient individual sachets. Each 5g sachet contains 50 mg of testosterone. To use, it is as simple as ripping open a sachet every morning and applying the gel to the shoulders, abdomen and lower back. Since it is an alcohol based gel, it takes only 5 to 10 minutes to dry off. It does not leave a greasy feel and does not stain the clothes.
However, it takes about 4 to 6 hours for the Testosterone from the gel to fully absorb into the fat layer under the skin. This is why for 4 to 6 hours after applying the gel you have to avoid, showering, swimming, excessive sweating or anything else that may wash the gel off.
Also after applying the gel, make sure to wash your hands thoroughly to avoid accidentally smearing the gel on someone who does not need it.
Here is a golden tip: Do not apply the gel on the day you have to do your Testosterone blood test. Any remnant gel on the skin can transfer via the needle into the blood tube causing the lab to detect an abnormally high level of Testosterone.
Testosterone Injections
In Singapore, there are 3 types of Testosterone injections available:
Short acting – to be injected about once a week
Medium acting – to be injected about once in 3 weeks
Long acting – to be injected about once in 10 to 12 weks
Of course these are guidelines and the actual dose and frequency of injection has be determined by your Doctor.
For short acting and even medium acting injections, some patients actually learn to inject themselves. This makes it a lot more convenient and saves you many trips to the Doctor’s office.
Estimated Serum Half-Lives of various Testosterone Esters.
T Propionate
T Phenylpropionate
T Enanthate
T Cypionate
T Undecanoate
20 hours
2.7 days
4.5 days
8 days
40 days
What are the side effects of Testosterone Replacement Therapy?
Many of the side effects of Testosterone Treatment are dose dependent. In other words, if you raise the Testosterone to a healthy physiological level, you really should experience very limited side effects if any at all.
Possible common side effects include:
- Reduction in sperm production and fertility
- Acne
- Male pattern hair loss
- Bruising and discomfort at the injection sites
- Skin redness at the gel application sites
Most of these side effects can be effectively managed.
Does Testosterone Replacement Therapy raise the Estrogen level?
Yes this is very possible and in fact rather common. Although it does not happen to everybody. The male body makes most of its Estrogen by taking Testosterone and putting it through a chemical change known as aromatization. So when a patient received exogenous Testosterone, the body can start making a lot more Estrogen. Excess Estrogen can lead to more body fat accumulation especially around the waist, hips and thighs. It can also cause gynaecomastia (male breasts) and mood swings. Your Doctor will monitor your Estrogen levels as part of your Testosterone Replacement Therapy. And make recommendations to keep it within a healthy range. If the Estrogen is really too high, your Doctor may recommend cutting down your Testosterone dose or giving you another medicine to either bring down the Estrogen level or reduce the effects of the high Estrogen.
Does Testosterone Replacement Therapy cause Prostate Cancer?
This is an urban myth that has been perpetuated ever since Testosterone Replacement became more popular. After much wrangling in the scientific community, we now know that Testosterone Replacement Therapy does not cause prostate cancer. In fact, the opposite is true: men with low Testosterone level are at a higher risk of developing high grade prostate cancers.
These days, we give Testosterone Replacement Therapy even to men who have undergone treatment for prostate cancer.
That said, your Doctor will still monitor your PSA (Prostate Specific Antigen) levels while you are on Testosterone Replacement. I very often see a rise in the PSA levels when I start a patient on Testosterone Replacement. This is never due to Prostate Cancer and always due to other conditions like Prostate Inflammation / Infection. This can be easily treated. And in the long run with patients on Testosterone Replacement, the PSA level actually does down.
In conclusion
Testosterone is an important hormone for men. The symptoms of a low testosterone level can cause significant distress. Early detection of a low testosterone level and prompt treatment can provide long lasting relief from the symptoms.
Have a question on Testosterone Replacement? Type it into the comments section below and I’ll get back to you as soon as I can!