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  • Writer's pictureDr. Heikens

Beyond Fatigue: How We Think About Testosterone Deficiency

A while ago I was talking to a healthy man in his early 30s that wanted to get his testosterone level checked. When I asked why, at first he simply said “I’m just curious.” 


It takes time to provide good care.


When I took the time to dig deeper, he was having some issues with sexual function. It turns out that a couple months earlier, he had difficulty maintaining an erection during intercourse with his partner. From there, it became a recurrent problem. His partner was patient with him, but the problem persisted. It was a constant concern with every encounter and it made him nervous every time.


He otherwise felt fine. His mood was pretty good except when thinking about his erectile problems, and he did have some work-related stress. When I asked if he was still interested in sex, and if he was still attracted to his partner, his response was a resounding “of course!”


We had a long discussion about his situation, and about the symptoms of low testosterone in men.


Fatigue and erectile problems are only some of the symptoms of low testosterone.


Generally, men with low testosterone can experience several symptoms. These include:


  • Significant fatigue or decreased energy

  • Depressed mood

  • Low libido (decreased interest in sex) with erectile dysfunction and lack of or reduced morning erections

  • Loss of muscle mass and sense of physical weakness (though this can take years to develop)

  • Hot flashes if testosterone deficiency is rapid and severe

  • Breast enlargement (rarely occurs after puberty, may be uncomfortable)

  • Infertility (rarely occurs after puberty)


In this specific situation, I spoke to my patient about erectile dysfunction, about which we have one or two Instagram posts about it as part of our men’s health series. However, the most important part of our conversation was this: when we are persistently worrying about something (like work, or even our own performance) we are not setting the stage for the rest of our body to optimally perform. 


What about other patients though? What if someone has symptoms that may suggest low testosterone?


There are a lot of reasons to have a lot of these symptoms.


Most importantly, there are a number of reasons that someone can have these symptoms, and while low testosterone is one possible cause, it should not be the only consideration. This is an important conversation to have with your physician to ensure you are getting an appropriate evaluation. This is an important reason to know how to speak with your physician about your medical concerns (stay on the lookout for a post about this in the future!).


If we end up diagnosing low testosterone, prior to considering testosterone therapy, there are more diagnostic steps that are recommended by experts. These usually will include a couple rounds of laboratory testing and possibly even imaging to determine whether there is an identifiable cause of your symptoms, so don’t be surprised if your physician suggests these.


Most importantly, it is important to try and identify reversible causes of low testosterone once it is found. Chief among these, in my experience, is obesity. Adipose tissue contains an enzyme called aromatase. This enzyme converts testosterone into estradiol, or estrogen. I have had several patients who had severe obesity who identified symptoms of low testosterone. When no other cause was found, we discussed weight loss as the best course of action. One patient I recall was understandably upset, but after a discussion of the potential risks of testosterone replacement therapy, he embarked on one of the most impressive weight loss journeys I have witnessed - he lost over 100 pounds through diet and exercise, over the course of a couple years. Most importantly, even though we made no changes to his medications, his testosterone level came back to normal and he felt great!



Other potential reversible causes of low testosterone can include:


  • Untreated sleep apnea

  • Use of steroids (either illicit anabolic steroids or steroids prescribed for inflammation)

  • Opioid use (especially higher doses)

  • Other medications

  • Alcohol or marijuana abuse

  • Nutritional deficiency or excessive exercise (exercise bulimia)


Testosterone is not always the answer.


Note that these are not all associated with there being a true problem with testosterone production (technically called “hypogonadism”), and in these situations the safest treatment is to reverse the cause rather than to add testosterone. So it is important to consider whether these are present, and address these first, before jumping straight to testosterone therapy. 


I have had some difficult conversations with men who feel they absolutely need testosterone therapy. Unfortunately, there are several possible adverse effects of testosterone therapy, and even if I feel treatment is warranted, it is still necessary to have a conversation regarding these effects before we start treatment. These effects may include:


  • Acne: testosterone is related to making skin more oily and may increase your risk for acne of the face, back, chest, or some combination

  • Infertility: strangely enough while testosterone is necessary for male fertility, testosterone treatment can cause infertility which may or may not be reversed by stopping

  • Elevated red blood cell count, or hematocrit: testosterone therapy can increase red blood cell production, which can lead to a condition called hyperviscosity syndrome that can cause blood vessel blockage (including stroke, heart attack, and DVT or deep venous thrombosis)

  • Prostate enlargement and prostate cancer: there is conflicting evidence but your individual risk factors for prostate cancer, as well as any possible urinary symptoms, should be discussed prior to initiating testosterone replacement therapy and further evaluation may be recommended

  • Breast cancer: there may be an increased risk of breast cancer and men with a family history of breast cancer should discuss this potential risk with their physician


Treatment requires monitoring.


Treatment is usually topical (a gel that is applied to the skin) or injected (usually once per week). Once treatment is started, it is super important to monitor testosterone levels to ensure that you are not being OVER-treated. It is also crucial to have regular monitoring for potential side effects with blood testing and physical exam on a regular basis. Finally, and I cannot say this enough: only apply the amount that is prescribed. Overuse of testosterone can cause any or all of the above side effects and is not safe.


In the end, as with so many other health conditions, it is most important to have a frank conversation with your physician about the specific symptoms you are experiencing. From there, we can start the appropriate evaluation to determine how to improve your symptoms!. 


But it takes time!


Unfortunately busy physicians in the fee-for-service system cannot always take the time needed to fully evaluate your concerns. This is another example of why health insurance is not the same as health care! If you would like to learn more about the model of care we practice at Health Matters Direct Primary Care that allows us to take the time to understand your symptoms rather than just throwing medications at you and hoping they help, please be sure to check out our website for more information, or schedule a free meet and greet appointment either with Dr. Anand or with myself.

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