Fatigue, low mood and poor concentration can be symptoms of testosterone deficiency in men. Photo / Bruno Aguirre, Unsplash
The biggest risk factor for low testosterone in men is simply getting older – but that doesn’t mean all men will feel the negative effects.
It was only when Rob’s* relationship had deteriorated to the brink of collapse that he finally went to his GP. “Life was just not going well for me, I was badly underperforming at work, going to the gym and not seeing results, and equally failing at home,” says the 44-year-old designer. “After some awkward ‘bedroom incidents’, shall we say, I’d started avoiding sex altogether, which my partner had taken personally. I thought she’d leave me if I didn’t try and get help.”
A blood test revealed Rob had low testosterone (low T). His GP referred him to an endocrinologist, and for the past six months he’s been having weekly testosterone replacement therapy (TRT).
“After three weeks it was honestly like someone had given me my life back,” says the father of two. “I didn’t know that low T was even a thing.”
Hypogonadism, as testosterone deficiency (TD) is also known, is most certainly “a thing”. It may affect up to 30% of men in the UK at some stage in their lives and, like Rob, most aren’t aware of the condition.
In fact, in a study of 2000 men last month, 55% were ignorant about the symptoms. The lack of education about TD, along with the stigma of seeming “unmanly”, means that 85% of men wait over a year before seeking treatment.
Dr Austen El-Osta of Imperial College London is one of the study’s lead researchers, which was undertaken in collaboration with the men’s healthcare platform Manual.
“Testosterone deficiency remains one of the least discussed and most under-recognised and under-treated conditions affecting men’s health,” El-Osta says.
“Classic TD symptoms – such as fatigue, low mood or reduced sex drive – are perceived by men as signs of ‘weakness’. Or they’re simply dismissed as part of normal ageing. There’s also confusion, thanks to how testosterone is associated with ‘toxic masculinity’ or as a performance-enhancing drug, which makes men naturally apprehensive. Instead of what testosterone is – a critical hormone and key pillar of men’s physical and mental health across their lifetime.”
Because of this delayed diagnosis and treatment, men are often left struggling in silence.
Furthermore, GPs often don’t screen for testosterone levels. The only way to change this, El-Osta says, is to destigmatise discussions about TD and get men educated about their own hormonal health.
The biggest risk factor for low testosterone in men is simply getting older.
“Increasing age is the most common reason for falling testosterone levels, with a 1% drop in levels from the age of 30 onwards,” says Dr David Huang, who also worked on the study and is director of clinical innovation at Manual. “By the time men reach the age of 70, their testosterone levels may have dropped by around 30% from peak levels.”
But that doesn’t mean all men will feel the negative effects.
“As we get older, our levels will drop,” says Dr Jeff Foster, a GP who specialises in men’s health. “The problem is that it is not an equal drop in all men – it affects men at different stages in their lives, and it also depends on how much you had to start with. But TD will likely affect 30% of men at some stage.”
Foster is reluctant to name an exact figure, as there have been different studies on the prevalence of testosterone deficiency. However, “I think we can safely say over 1 million men in the UK will be suffering with low testosterone at any one time.”
The second biggest cause is obesity or being overweight, “as this directly reduces testosterone levels as well as increasing estrogen and insulin resistance”, Foster says.
Simply shedding the excess weight is often not enough to solve the problem.
“Telling someone who has no energy and is tired all the time with depression that ‘all’ they need to do is lose weight won’t cut it,” Foster says.
Instead, he believes prescribing patients TRT can give them the motivation they need to lead a healthy life.
Other common causes of low T, Foster says, include medical problems like diabetes, high blood pressure and asthma, as well as some anti-fungal medications, antidepressants and painkillers.
Exercising too much or not enough can also contribute.
“A lack of both strength training and cardiovascular exercise can contribute to reduced testosterone,” Huang says. “Both the quantity and quality of sleep matter. Factors like excessive screen time and the ‘always on’ nature of modern life interferes with restorative sleep, which in turn affects hormone levels.
“There’s also the prevalence of endocrine-disrupting chemicals (known as EDC) which we come into contact with every day in modern life ... [that] disrupt our regular hormonal balance in the body, including testosterone production.”
Other substances like alcohol, opiates and medications all spell bad news for T levels, as does poor diet. “Men are very sensitive to external factors impacting their body’s testosterone production,” Huang says.
The most common scenario Foster sees in his practice is a man aged 35-plus describing increased fatigue, maybe struggling to get through the day without relying on caffeine. “Many men say they get home and need a nap,” he says.
People might assume TD mainly impacts libido and erectile function, but “testosterone works more systemically in the body to significantly impact mood, cognition, energy levels, sleep quality, muscle mass, bone density and even cardiovascular risk”, El-Osta says.
A decreased sports ability was reported in 35% of men with low T, the study found.
“Men may find that while they go to the gym and train just as hard, they can’t put on muscle and get fatter despite nothing changing in their diet,” Foster says. “Interestingly, they also often have poorer sleep even though they are always exhausted.”
The effects aren’t just physical, Foster says. “Men become more reclusive with low T. They lose their confidence, drive and motivation. A lot of partners say the men become more irritable, like the joy in their lives is lost, and low mood can in turn develop into true social phobia.”
The damage this wreaks on men’s home lives can be devastating. In fact, failing relationships are a common catalyst for men to eventually seek professional help.
“The impact is not only profound for the men themselves, but also for society as a whole, considering that during those years [of not being diagnosed], many are underperforming at work, struggling in relationships, and finding it harder to show up fully as parents,” Huang says.
“Men with TD often describe feeling flat or less motivated, more anxious and more fatigued,” adds El-Osta. “We’re now seeing growing evidence also linking TD with depression, metabolic syndrome and reduced lifespan if left untreated.”
Poor concentration and memory issues are common, Foster says. “One chap I saw who was 65 thought he had dementia, but it was just low T.”
Often, men only recognise how badly low T affects their general lives, including their performance at work, after starting TRT.
As Huang says: “People are adaptable, often compensating for symptoms for years before it tips over the edge, and this realisation only comes in hindsight.”
Erectile dysfunction affects half of men in their lifetime, Foster says, but that doesn’t necessarily mean low T.
A better indication is morning erections – men should still be getting them a few times a week throughout their lives and into their old age.
“In advanced cases of TD, we don’t just see erectile dysfunction but also a loss of morning erections,” Foster says.
A third of men with TD report having a low libido. While this may not mean their sex life has ended, they might have lost enthusiasm for it.
“More common in the early stages is just more of a general disinterest in sex,” Foster says. “So if sex is offered, that is fine, but men who previously were more sexually active just stop thinking about it as much.”
Less common symptoms include dry skin, dry eyes, joint pain, night sweats, flushing and loss of body hair.
“I even saw a patient with gum disease secondary to low testosterone,” Foster says.
He stresses that it’s not necessary for men to have all three sets of symptoms – mental, physical and sexual – for low T to be an issue. “Many will just feel they are not themselves but they don’t know why.”
The key with the treatment of low T, Foster says, is to work out why it is low.
“Low T is either caused by lifestyle factors, other medical problems (such as diabetes or low blood pressure), or age/genetics that just means it runs out.”
Certain rare genetic conditions – such as Klinefelter syndrome, when males are born with an extra X chromosome – can lead to low testosterone levels, although many men with Klinefelter’s may be unaware they have it and a genetic test is needed for diagnosis.
“What is more common is the natural variation in testosterone requirements between individuals – both men and women,” Foster says. “There is growing interest in the role of genetics in testosterone production and how the body responds to it. Testosterone receptors are found in virtually every organ, and researchers are investigating how genetic variations in these receptors may influence sensitivity, and in turn the amount of testosterone an individual needs.”
While lifestyle factors can improve testosterone levels, Foster says that in most men, they’re a small contributing factor.
“For the majority of men, they will need to go on to testosterone replacement therapy. This is literally a hormone replacement for men. It comes as either a topical treatment or mini-injection every week and is generally tolerated really well.“
Huang would like to see men discussing the option of TRT in the same way women now openly talk about HRT for menopause symptoms.
“We’ve changed the way we see estrogen’s importance in women during menopause, acknowledging the overwhelming benefits and realising the risks were over-inflated,” Huang says. “Now it’s exciting to publish research that opens the door to this destigmatisation of testosterone in men.”
Go to your doctor and ask for a blood test. There are also finger-prick blood tests available that you can do at home to get an indication of your testosterone level. GPs will likely refer you to an endocrinologist if yours is low.
Doctors with specialist knowledge in hormones are best placed to treat testosterone deficiency, Huang says.
“Many GPs aren’t well equipped to treat men like this, nor are they looking to treat the cause. Similar to women who may have low moods because of menopause, and GPs just throw antidepressants at them, there is a gap in education we still need to bridge for men with low testosterone.”
In Britain, men are most commonly offered TRT in the form of a topical gel or an injection that’s administered once or twice a week, or once every 12 weeks.
“For the short-acting injections, patients can administer their own medicines (usually via subcutaneous or intramuscular injections) and for the long-acting, 12-week injections, these are done by a nurse or doctor in a clinic,” Foster says.
In addition to conventional TRT, other medications are used that are not strictly external testosterone but that can be used to increase testosterone levels.
“The key to all these medications and choices is that there is no ‘one size fits all’ approach to TRT,” Foster says. “The best medication is the one that suits the patient based on their blood results, medical history and lifestyle preference. It should be a joint decision between the patient and the doctor.”
*Name has been changed
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