(And male menopause, aka andropause)
There’s something of a divide in the medical community.
To give testosterone to men who maybe don’t need it, or not.
It follows a deeper dividing line:
- basic health vs. performance optimization
- healthcare for all vs. pure concierge
Basically, need vs. want.
When the topic of testosterone comes up, many loaded topics get dredged up with it: 40-year-old guys trying to be 20, getting scary big and strong, and whether doctors might be enabling more chest beating and toxic masculinity.
In my experience, politics and Posturing Over Issues tend to disappear in the exam room. In the one-on one, individuals come clean about their lives and what’s weighing on them.
And the concerns of most men who ask about testosterone are honest and worrisome.
The question is whether prescribing testosterone is the right answer.
What the conventional guidelines say
Good parts version: you’re only a candidate if you have BOTH of the following:
1) a sexual problem like low desire for intimacy or poor erections
2) a certifiably low total testosterone level, which is below approximately 250 ng/dL, though different cutoffs exist based on age and obesity.
If your main problem is brain fog, sorry.
Low energy? Nope.
Not making the strength and size gains in the gym you feel you deserve? I’ll bet.
Most important of all, if you’re 50 and your total testosterone is, say, 375, conventional medicine says you shouldn’t be taking testosterone.
Not because regular doctors are prissy dorks, but because testosterone treatments can have negative side effects, including blood clots (can be fatal), raising cholesterol (can contribute to heart disease), and accelerating prostate cancer (no bueno). There’s caution for a reason, and one of the first principles of medicine — THE first principle, in fact — is Primum, non nocēre: First, do no harm.
Why we’re still talking about this
Because not all physicians are conventional.
There’s a sizable contingent that believes that male menopause, aka andropause, is a real thing, despite it not being recognized as a valid diagnosis in current medical practice. That men past 40 or 50 are coming forward with concerns about quality of life changes that might be treatable:
- chronic fatigue
- decreased motivation
- difficulty concentrating and brain fog
- poor sleep quality
- decreased physical strength and increased total body fat
- decreased sexual desire and performance
That this collection of symptoms is caused by reduced testosterone can be debated. A lot of these symptoms overlap with signs of depression and stress.
That men are coming forward with them is indisputable. Dismissing them would be no more acceptable to a doctor than dismissing a woman’s concerns about similar symptoms.
If the first principle is Do No Harm, the second should be Hear Me Out.
Where the total testosterone “should” be
The range of normal is pretty wide: between about 200 and 1200, depending on the lab.
That’s a 1,000 point spread.
No question, 200 or lower is too low; if it’s consistently this level, there’s no argument about discussing treatment.
The real range of decent testosterone varies, depending on the medical society:
- Endocrine Society: 300-900 ng/dL for healthy men
- American Urological Association: 450-600 ng/dL
450-600 ng/dL appears most often as the cited target, regardless of patient age, if treating with testosterone.
If 500 is good, is 800 better?
In a word, no.
Studies have shown that sexual function benefits plateau after testosterone levels reach the normal range, with no evidence for symptom relief going from 500 ng/dL to 800 ng/dL.
What does go up is the risk of getting blood clots from the body putting out more red blood cells. This goes up in a dose-dependent way: the more testosterone taken, the higher the risk of blood thickening and clots forming.
Clots in the brain, lung, or heart can be fatal.
What if a patient feels better at 800 and their labs look good?
This is getting into the weeds, where such a patient really needs to be discussing specifics with their own doctor.
From an educational standpoint, I’d argue that the main takeaway is to have what is called shared decision-making with one’s doctor.
What exactly are the symptoms of concern? How likely are they, really, to be caused by low testosterone, and to be improved by supplementing? What are the possible risks and side effects, and are they worth it?
There’s a lot of bro science out there, and just because John Smith the bull-necked 58-year-old YouTube influencer takes it doesn’t mean that you should.
I’ve said it before regarding supplements: it’s best to take them if they’re safe and they actually improve something (how you feel or how your tests look), rather than taking them “just because” or “because I look up to XYZ and they take it.”
This goes double for prescription medications.
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