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Monday, May 28, 2012



Unlike female menopause, which happens to every woman, and is abrupt and associated with aging, not all men become testosterone deficient with aging. It varies from man to man, and it is mostly associated between genetics, and environmental and behavioral factors. Male menopause is another name used to describe the decrease that happens with men as they age. There are other reasons a man can develop low testosterone and it is important to properly identify the cause of the problem. Unfortunately, there are no well-defined criteria on how to make a diagnosis, and when to start treatment. It remains an art. There are guidelines though, and the use of them helps the medical community make better decisions.

The diagnosis of low testosterone has increased in recent years. It has been reported that 12%, 19%, 28%, and 49% of men greater than 50, 60, 70, or 80 years of age, respectively, fit the criteria of having low testosterone.

There are a lot of factors that need to be taken into account when considering if a man has low male hormone. A thorough clinical history and physical examination and a comprehensive set of laboratory tests and even radiological tests need to be performed with your doctor in order to make a clear cut determination if a man has low testosterone.

Questionnaires are a good resource when considering if this may be a problem and may guide you to seek medical attention sooner. This is a set of questions set to be asked to a man, so when I use the word you in the questions, I am referring to a man. You can answer in two different ways; a YES or NO format, or give it a numeric value, meaning 0 if you have never had the problem and 10 if you always have the problem. In the case it is a definite YES, you can assign it a 10, and if it is a straightforward NO assign it a 0 value. At the end of the questionnaire, you can then add up your scores.

1. Do you notice that you developed male sexual characteristics late in life?

2. Do you have decreased libido, sex drive or sense of desire?

3. Have you noticed a decrease in your sexual activity?

4. Have you noticed a decrease in the morning or spontaneous erections?

5. Are your erections less frequent, less strong?

6. Do you climax?

7. Do you have a decreased amount of semen ejaculate?

8. Have you noticed your testicles change in size or become smaller?

9. Have you had inability to father a child or have been evaluated for infertility?

10. Have you noticed that you are feeling more and more tired as time goes by?

11. Have you noticed that your motivation or energy levels have dropped over time?

12. Have you noticed a decrease in ‘enjoyment of life in recent years?

13. Do you feel less confident?

14. Has there been a decrease in your work performance?

15. Have you noticed decreased memory or a change in your ability to concentrate?

16. Are you feeling sleepier during the day?

17. Do you suffer from insomnia?

18. DO you snore frequently?

19. Are you sad or grumpy?

20. DO you suffer from depression?

21. Are you overweight?

22. Have you noticed an increase in your abdominal fat and thinning of your arms and legs?

23. Have you noticed a decreased sense of strength or endurance?

24. Have you noticed a recent deterioration in your ability to play sports?

25. Have you noticed your muscles decrease in size?

26. Do your muscles ache?

27. Have you developed arthritic symptoms in the recent past?

28. Have you lost height?

29. Have you had a fracture falling from your own height?

30. Do you have osteoporosis?

31. Do you have dry skin?

32. Do you suffer from elevated cholesterol?

33. Do you suffer from diabetes?

34. Do you suffer from high blood pressure?

35. Are you on prescription medication for blood pressure?

36. Do you drink more than 2 alcoholic beverages every day?

37. Do you have breast discomfort or enlargement?

38. Have you noticed loss of body hair, reduced shaving?

39. Have you felt hot flushes or sweating episodes?

40. Have you tried Viagra, Cialis or other ED drugs and noticed they did not work?

41. Have you used marihuana in the recent past?

42. Have you been on prescription pain killers?

Now that we have asked the questions, you can add your scores.

If you answers totaled a score >250: You need to discuss this with your physician or care provider to consider testing for low testosterone as well as other medical conditions such as diabetes or elevated glucose, elevated cholesterol, high blood pressure and heart disease .

If you scored between 100 and 250, you are likely to have a problem and it would be a great benefit to you to have a conversation about the problems you are having with your health care provider, and consider testing for low testosterone and other medical problems that could be causing the way you feel.

If you scored 100 or less, it is still probable that you may have some problems with your health, and again, if you feel these issues are connected, you may want to look into these matters further and consider a visit with your doctor and health care provider.


There have been many debates on this issue. Low testosterone, also called Hypogonadism, is often overlooked, even in the presence of complaints and physical changes. This is because men tend not to want to discuss this with their doctor, or the complaints are attributed to aging or other medical problems.

As men age, there is an increased risk of cardiovascular disease, depression, osteoporosis, and diabetes. Unfortunately, despite studies that have shown the association between declining levels of testosterone, and men’s health and wellbeing, the diagnosis needs to be a clinical one where both the patient’s complaints as well as the laboratory levels need to be taken into consideration. There have been numerous articles, committees and recommendations published by leaders in the medical field. Some look at at this problem from an endocrinologist point of view, some look from an urologist point of view.

In 2009, in order to ensure broad outreach, the International Society of Andrology (ISA), the International Society for the Study of the Aging Male (ISSAM), the European Association of Urology (EAU), the European Academy of Andrology (EAA) and the American Soceity of Andrology (ASA) published recommendations in all their journals simultaneously.


Low testosterone in a man, Hypogonadism, is a clinical and laboratory (biochemical) problem that can be associated with advanced age, and this condition may result insignificant detriment to the quality of life of an individual and may even adversely affect the function of multiple organs in the body.

At the time of the diagnosis, the person needs to have the presence of complaints and clinical signs on examination that would be suggestive of testosterone deficiency. This presentation needs to be correlated to an abnormal laboratory test.

An abnormal laboratory test is when the value of the Total testosterone is 2.5 standard deviations below the mean normal testosterone in young adults (627ng/dl). One standard deviation is equivalent to 123ng/dl. So in essence to have a clinically relevant low testosterone the Total Testosterone value should be LESS THAN 381ng/dl. Some studies round it up to less than 300ng/dl to be clinically significant.

Unfortunately it does not stop there. It is not enough to have low testosterone, the reason by which it decreased needs to be identified, and thus a more in-depth clinical, physical and laboratory assessment is necessary.


When a man has low testosterone, it can be because of two major pathways:

a. Primary: If the brain is sending the messages to the testicles to work, but they are not doing the ‘job’, then it is a primary problem of the testicles, Primary Hypogonadism.

b. Secondary: If the brain is not sending message to the testicles to produce enough testosterone, it is called Central. Also called Secondary Hypogonadism, because the problem really does not lie in the testicles, the problem is in the brain.


As I stated above, it is not enough to just know that a man has low Testosterone (Low T). The cause needs to be identified because this will determine the course of the treatment and may even identify even more serious problems that need attention. Please make sure to discuss the following tests so they can be ordered if necessary when considering other causes of low testosterone with your doctor.

After screening with Total Testosterone and a low value has been found, such as lower than 300 ng/dl, a repeat test is needed. This time please make sure you go to the lab, in a fasting state. This means that you have not had food for the last 8 hours. It is also important that you have the lab test done early in the morning, as hormone levels are very sensitive to the time you wake up (circadian rhythm).

When considering other tests, they need to be taken into the context of other complaints that may be present and lead the doctor to make informed decisions and avoid excessive testing and high lab bills. This is a list of the tests that should be considered when doing a thorough work up for low testosterone:

1. Total testosterone

2. Free Testosterone

3. Sex Hormone Binding Globulin

4. Comprehensive Metabolic Profile (CMP)

5. Luteinizing Hormone (LH)

6. Follicular Stimulating Hormone (FSH)

7. Prolactin (PRL)

8. Fractionated Estrogens

9. Progesterone

10. Thyroid Stimulating Hormone

11. Am Cortisol

When doing these tests, the doctor can determine if the cause of the Low Testosterone. The different possibilities that cause a low testosterone in the blood are as follows:

1. Andropause, or low T associated with aging

2. Primary failure of the Testicles to produce testosterone

          a. Genetic Disorders (Klinefelter’s syndrome)

          b. Orchitis – or inflammation of the testicles

          c. Trauma

          d. Radiation and Chemotherapy

          e. Undescended Testicles

3. Secondary failure of the Testicles due to a brain problem that does not secrete LH and FSH the hormones necessary to stimulate their function

          a. Damage to the pituitary gland

                i. Kallman Syndrome

                ii. Brain tumor

                iii. Brain Trauma

                iv. Radiation

                v. Hematochromatosis

                vi. Sarcoidosis

                vii. Tuberculosis

So, in summary, I have presented to you a set of questions that can help a man determine if there may be any reason to think that there is low testosterone in the body. If that is the case, it should be addressed with the doctor or care provider so that the appropriate tests can be done, and treatment not only for the complaint but also for the cause, be initiated. In doing so, this may be done early and avoid future complications later as a consequence of low testosterone, and the original problem itself.

In my next blog, I will address andropause, male low testosterone associated with aging, and we will address the different kinds of treatment available.

Stay tuned,

Margarita Ochoa-Maya, MD


  1. The natural ways to treat testosterone levels and the most worsen days are those when your partner want to have sex and you continuosly avoid her, that is the exact condition when the men must concern the doctor for Testosterone Replacement Therapy that could restore male features again.

  2. That’s a great blog. My husband has recently been diagnosed with low testosterone levels. He’s taking Ageless Male, a supplement specifically designed to reinstate the body’s dwindling testosterone production. There are people who think of Ageless Male as a scam, but that’s entirely false. This product contains the right ingredients in the right proportion for stable testosterone levels that helps men enjoy a healthy sex drive and optimum metabolism. It has worked brilliantly for him and several other men, helping them to easily overcome the effects of old age and falling T levels.