Low Testosterone: The Hidden Link to Osteoporosis, Diabetes, Cardiovascular Disease, and Depression
Tuesday, April 18 12 p.m. - 1 p.m. EST
Welcome to Viewpoint, a live discussion forum on washingtonpost.com. This forum offers washingtonpost.com sponsors a platform to discuss issues, new products, company information and other topics.

Low Testosterone: The Potential Link to Osteoporosis, Diabetes, Cardiovascular Disease, and Depression

Why are millions of American men as young as 40 experiencing symptoms commonly associated with aging? And why are these men doing nothing to treat these debilitating symptoms?The answer is that most men in America are unfamiliar with Low Testosterone (Low T) or hypogonadism, a medically recognized and often treatable deficiency defined by abnormally low levels of testosterone. Many men rationalize their symptoms as simply consequences of getting older. However, they may in fact have Low T.

Dr. André Guay, director for the Center for Sexual Function at the Lahey Clinic Northshore, was online to answer your questions about Low Testosterone, symptoms, testing and diagnosis, FDA approved treatments, and the potential link to osteoporosis, diabetes, cardiovascular disease, and depression.

Dr. André Guay is a clinical assistant professor at Harvard Medical School and director of the Center for Sexual Function at Lahey Clinic Northshore. He received his MD degree from the New Jersey College of Medicine in 1968. His residency in Internal Medicine was performed at Saint Vincent Hospital, and he conducted specialty training in endocrinology and metabolism at the Mayo Clinic. Dr. Guay was the Head of Endocrinology for the U.S. Navy before joining the Lahey Clinic in 1977.

The transcript follows.


Moderator: Welcome to Viewpoint. Today our topic is low testosterone with our guest Dr. Andre Guay. We've received many questions, so let's get started!

Dr. André Guay: Thank you for inviting me to participate in this chat. This is a great opportunity for us to address the topics of low testosterone and aging. I'm hoping we will all learn something from this exchange of information.


New York, N.Y.: What is testosterone and why do men need it? Isn't testosterone just about the male libido?

Dr. André Guay: In the male body, testosterone is the most important sex hormone produced. At puberty, testosterone is the hormone that is primarily responsible for producing and maintaining the typical male attributes including:

- Growth of facial and pubic hair
- Deepening of the voice
- Increase in muscle mass and strength
- Growth in height

Testosterone helps maintain sex drive, fertility, male hair patterns, muscle mass and bone mass.


Baltimore, Md.: What is low testosterone and what are the symptoms?

Dr. André Guay: Low testosterone, also called Low T or hypogonadism, is a treatable clinical condition defined by abnormally low testosterone levels. Testosterone deficiency in men leads to symptoms that can often be treated when tested and diagnosed by their doctors. Typical symptoms of Low T include:

- Increased irritability or depression
- Fatigue
- Inability to concentrate
- Reduced muscle mass and strength
- Low sex drive and erectile dysfunction
- Decreased bone density and osteoporosis
- Increased body fat


Columbus, Ohio: Should the average adult male be concerned about low testosterone (low T)?

Dr. André Guay: Yes. Low T affects approximately four to five million American men. However, it is estimated that only five percent of affected men currently receive testosterone replacement therapy.


Orlando, FL: Should I ask my primary care physician or a specialist for information about Low T?

Dr. André Guay: Ask your doctor if he or she has seen any patients with Low T in their practice and what their experience has been if they needed testosterone replacement therapy. The testing is achieved through a simple blood test that can be performed by your primary care physician, who may wish to refer you to a specialist such as an endocrinologist or urologist.


Charleston, S.C.: How do you test for Low T? How often should I be tested?

Dr. André Guay: Low testosterone can be diagnosed by a simple blood test performed by your physician. Because testosterone levels vary throughout the day, the test is generally performed in the morning when testosterone levels are highest.

Those men experiencing symptoms of testosterone and those at increased risk of having low testosterone may want to talk to their physicians about getting tested regularly.


New York, N.Y.: What is considered normal for testosterone levels?

Dr. André Guay: The normal range for total testosterone in men is generally between 300 nanograms per deciliter (ng/dL) and 1,000 ng/dL, depending on the lab performing the test and the methodology used.


Dallas, Tex.: What does Low Testosterone have to do with aging? Can treatment make me feel younger?

Dr. André Guay: Many of the symptoms of Low T are commonly attributed to the natural aging process, and consequently many men with Low T fail to seek treatment for their condition. TRT can’t reverse or slow the aging process. However, the point is that aging may not be the problem.

The diagnosis of Low T and treatment with TRT may encourage a more active lifestyle and alleviate symptoms such as decreased energy, low libido, reduced muscle strength, increased body fat, weaker bones, and mood swings.

Importantly, normalizing testosterone levels may reduce risk of serious medical conditions such as metabolic syndrome, type II diabetes, coronary heart disease, osteoporosis and depression.


Raleigh, N.C.: What are the treatment options for Low T? What are the pros and cons?

Dr. André Guay: TRT is available in a variety of FDA-approved dosage forms including injections, gels and patches. Oral forms of TRT are rarely prescribed because they can cause damage to the liver. However, TRT can help provide the following benefits:

- Improved mood
- Increased muscle mass and strength
- Increased sexual interest
- Improved erectile function
- Improved or sustained bone density
- Decreased body fat

Men with prostate or breast cancer should not use testosterone replacement therapy, and all men should see their doctor for a prostate cancer exam before initiating TRT.


Columbia, S.C.: Could my symptoms of Low T be a sign of a more serious health problem?

Dr. André Guay: There is mounting evidence linking low testosterone levels to long-term medical conditions such as metabolic syndrome, type II diabetes, coronary heart disease, osteoporosis and depression.

Several published studies have shown the beneficial effects on quality of life by normalizing testosterone levels with testosterone replacement therapy.


Huntington Beach, Calif.: What is the diagnostic test for this condition? Is it normally included in most annual tests?

Dr. André Guay: The total testosterone blood test is the most commonly used. It is not a standard blood test like cholesterol or PSA. You and your MD have to review symptoms of low T and see if it is appropriate to test.


San Diego, Calif.: What is known about the relative risk of prostate cancer in patients given testosterone replacement therapy?

O Biederman MD

Dr. André Guay: To date, there is no conclusive evidence that testosterone levels in healthy men or that testosterone replacement therapy causes prostate cancer. On the other hand, men with prostate and breast cancer cannot use testosterone therapy.


Sheldon, Vt.: I was tested and I have very low levels of testosterone.

My doctor feels it is a waste of time for me to take shots as it will not do me much good.

Your comments on this?

Dr. André Guay: If your testosterone is very low, then I would seek a second opinion, perhaps from a specialist such as an endocrinologist or urologist. There are FDA approved treatment options available other than injections.


Kailua, HI: I don't fit the profile of your description because I'm a female. But I have had a long term problem with debilitating fatigue and recently my only blood indicator that could be addressed as possibly contributing was a trace level of testosterone. The physician who made the suggestion prescribed a half dose of a 1% tube of Testim testosterone gel (2.5 GM) daily. The compounding pharmacy would not fill the prescription as they felt it was too strong for a woman.

I have been afraid to try to have it filled at other places without a second opinion. Could you please make a suggestion as to the value of this trial for me and to the strength that would be appropriate for a woman? Thank you, Maxine

Dr. André Guay: Testosterone deficiency in women is a new field and very controversial. The FDA has not approved any form of testosterone replacement in women. It is therefore, not appropriate for me to comment on this at this time.


Granville, Ohio: I'm 57 with T levels just below the accepted range. Can low T cause insomnia and low libido?

Dr. André Guay: Yes, decreased libido is definitely related to low T. Some patients do relate sleeping difficulties, which are corrected with testosterone replacement.


Dublin, Calif.: Dr.,
don't testosterone shots create infertility in men? I hear testosterone shots stop sperm production and are sometimes used for birth control purposes.

Dr. André Guay: Yes, testosterone treatment can lower sperm counts. Men who desire fertility need to consider other options for treating low T, or postpone treatment until fertility is no longer an issue.


Everett, Wash.: What type of replacement therapy do you recommend for levels around 115 for a man in his late 50's (total testosterone)?

Dr. André Guay: Any level of testosterone below 150 definitely requires treatment, but also there is a possibility that a full evaluation of the pituitary gland should be done. If a practicing physician is not comfortable with this, a referral to an endocrinologist would be appropriate.


Los Angeles, Calif.: What levels of testosterone (numbers) should a man have, including free testosterone? I'm 75 and had a significant drop in energy and sex drive a couple of years ago.

Dr. André Guay: The most commonly used test is the total testosterone and the most commonly used threshold is 300ng/dL. Below this one would consider testosterone deficiency.


Toledo, Ohio: I'm 60 and have been on TRT for about three years. Is there a point at which I should stop treatment?

Dr. André Guay: This depends on many factors: if the problem was primary testicular degeneration, then the treatment is then for life. If the problem is due to an acute illness, or sleep apnea, that has been corrected, then a trial off therapy might be considered to see if the levels come back to normal.


New York, N.Y.: Has any link between low testosterone and obesity been >identified? To that end, how can this be related to aging?

Dr. André Guay: Yes. Current data states that low testosterone can be related to excess weight, especially when the BMI is greater than 30. This is in addition to the normal aging drop in testosterone. Weight loss can reverse this in many cases.


DC: I began with a low T count of 163 and am now hovering around 350 using Androgel. Is this a good level to stay at?

Dr. André Guay: The level of 350 is certainly appropriate for men over the age of 50, as long as most symptoms have been alleviated. For men under 50, this may be inadequate requiring titration of the medication.


Palmer, Alaska: What is the connection between sleep apnea and low hypogonadism?

Dr. André Guay: Sleep apnea causes low oxygen in the blood, which then inhibits the pituitary from sending signals to the testicle. This results in low testosterone production. This is often correctable with treatment of the sleep apnea.


Northridge, Calif.: Last September I found myself getting exhausted doing yard work. I took the therapy for 1 month but felt no improvement. I am 53. Is this common? How long does it take to see results?

Dr. André Guay: The most important factor is whether or not your testosterone was low before going on therapy. If the level was normal, testosterone therapy will not help. Also, it may take several months to notice improvement. Another factor is whether or not the levels were put into the normal range with therapy.


Clearwater, Kan.: Would low T create a lack of interest in sex or no desire to deal with a sexual dysfunction such as premature ejaculation?

Dr. André Guay: Low testosterone can be related to both a decrease in libido and in premature ejaculation.


Sumerduck, Va.: I underwent a vasectomy in 1982. Could this result in low testosterone levels? If so, what would be the solution?


Dr. André Guay: No, there is no relationship between testosterone levels and vasectomies.


Arlington, Va.: I have been living with HIV for nearly 20 years,and low testosterone appears to be even more rampant among HIVers but also largely discounted by health care providers until we push. Is your research tracking this phenomenon, too?

Dr. André Guay: At least 30% of HIV-positive people have low T. That number is greater than 50% for AIDs. Research has been done in this field for both men and women and testosterone replacement has helped many of these people.


Monroe Township, N.J.: Can this run in your family?

Dr. André Guay: There are certain genetic conditions that can cause low T- this would allow it to run in the family.


Md.: Dr. Guay, I was informed by my doctor that my testosterone is low. I used the gel and found it to be satisfactory. However, I did notice a discoloration on my shoulders so I discontinued use. I work out all the time and really feel good. However, I do feel depressed at times and want to be left alone.

Can you give me some advice?

Thank you.

Dr. André Guay: Discoloration of the skin is not reported that I know of. I would suggest consultation with a dermatologist to see if there are other conditions that need to be addressed.


New York, N.Y.: Would taking 25 mg of DHEA help solve the problem?

Dr. André Guay: I presume this is for treatment of low T in a man. This small dose of DHEA will have no effect whatsoever. The production of DHEA is not regulated by any agency and the amount of actual material in certain brands may be very low. We do not recommend this at all in treatment of low T in men.


Salvador,Bahia,Brasil: I am a 66 year old man, and my testosterone is about 400.
Can any medicine today help-me without risk of cancer?

Dr. André Guay: A testosterone of 400 in a 66-year-old man would be considered normal.


Bridgewater, N.J.: What are the genetic conditions that can cause Low T?

Dr. André Guay: Kleinfelters Syndrome. Kallman's Syndrome. Congenital 5-alpha reductase deficiency. Familial clusters of pituitary tumors, and a variety of other genetic conditions.


Marshalltown, Ind.: There is much being said about the estrogenic effects of many common substances, from soy and food additives to herbicides and pesticides. What should men take particular pains to avoid? What nutritional factors are known to positively affect testosterone levels? What herbs and nutraceuticals have been demonstrated to elevate testosterone levels in a "natural," safe manner?

Dr. André Guay: Phytoestrogens in the environment is being studied and does occur but the effect on humans is controversial at this time.

Protein calorie malnutrition certainly can affect the body's testosterone level, as can obesity. There are no specific foods or herbal products that have been proven to have a positive affect on T levels.


Leesburg, Va.: What is the difference between testosterone therapy and the steroids people take for muscle gain?

Dr. André Guay: Testosterone is the body's natural sex steroid. Similar substances have been used by body builders for muscle and strength enhancement but usually in far greater doses than is physiologically healthy.


Kerhonksen, N.Y.: Can the patches or the gel still work if they are applied in areas other than recommended?

Also: why are there cautions against applying either to the scrotum?

Dr. André Guay: Patches and gels have been recommended to be applied in specific areas because of clinical research that has shown that it works the best in these areas. The first patch that was developed and applied to the scrotum caused very high levels of metabolites of T which may have had negative health consequences. For these reasons, and the fact that these patches often fell off, we no longer use them. Current patches and gels should be applied according to manufacturers' instructions.


Atlanta, Ga.: Does low T have any effect on memory or any relation to Alzheimer's.

Dr. André Guay: Low T has been implicated in cognitive dysfunctions, including ability to concentrate, calculate, as well as memory. There is early research suggesting that degenerative conditions like Alzheimer's may also be related to sex steroid deficiency.


Northridge, Calif.: I was diagnosed with low T and used the gel. The instructions were to put it on the chest. There is so much of the gel that I must cover my chest and stomach to apply it all…and it is messy. Can it be applied to arms and legs? Sides? Any other suggestions

Dr. André Guay: The gel you are speaking of can be applied to the arm and shoulder area as well as to the lateral chest and abdomen.


Memphis, Tenn.: My husband was treated for depression about 5 years ago and prescribed Effexor. He is still on that medication and up until approximately a year ago, was a heavy drinker.
In January, he was found to have low testosterone and has been put on medication.
We have been married 16 years, and during that time he has had a low sex drive and also he drank during that time. He blames his low testosterone on the Effexor. I disagree. What are your thoughts?

Dr. André Guay: Effexor, and other SSRI antidepressants, can lower T, either directly or through the stimulation of prolactin from the pituitary. Excess alcohol use in the past can also depress the pituitary's signals to the testicle. The important point here is that there are multiple causes of low T, and several causes could affect a man at different stages of life.


Richmond, Va: My husband's T levels are within normal range. He has scarring on his liver and is on medication for this. Is there anything he can take to elevate his T level?

Dr. André Guay: There is no benefit to raising T above the normal level.


Palm Springs, Calif.: I have had a quad bypass, and both carotid arteries cleaned. I also have harvested veins in my arm and legs and occlusion in other veins. Should I ask my cardiologist for a prescription for testosterone? Is this dangerous in my physical state?

Dr. André Guay: There is no contraindication for using testosterone in your case as long as the blood test shows a definite deficiency. More and more evidence of late is relating low T to an actual risk of cardiovascular problems, but more long-term studies are needed before any specific recommendations can be made in this area.


Saskatoon, Sask, Canada: Since I'm on Lupron for prostate cancer metastases, I'm a candidate for all the ailments mentioned, right?

Dr. André Guay: Lupron treatment can certainly lower T and cause symptoms of testosterone deficiency. Unfortunately men with prostate cancer cannot take testosterone replacement.


Moscow, Idaho: I am on high blood pressure medication such as Labetalol, Hydraclorithiazide, Gemfibrozi, Benazapril, Verapamil, and Clonidine. I have a history of high pressure with no apparent effect from several medications. I am not overweight and I have had my kidney functions checked out, which was OK. Clonidine is the most recent medication I am on, which has decreased the pressure somewhat. However, my question is: do these medications affect my testosterone level, and if so, should I be taking something to supplement this deficiency. I am 66 years old and have been on HBP medications for many years. I hope I have given you enough information to respond to my question. Thank you.
Jerry L. Brown

Dr. André Guay: Certain medications can decrease T levels. More importantly, chronic illnesses like hypertension can lower T levels. Your physician could do a blood test to determine whether you are deficient or not.


Dorval, Quebec: I was under the impression that T increased as men aged, hence balding. Another impression I have is that T is produced through activity, more muscle equals more T.

Thanks for reading this.


Dr. André Guay: Testosterone does not increase with aging. Balding is more related to a genetic tendency in your family than to T levels.


Ft. Collins, Colo.: Dr. Guay:
My urologist wants me to have my testicles removed to reduce my testosterone to slow down cancer growth in my prostate cancer as the sole treatment. I am 78 years old. I am very active in sports and participates 3 times weekly in sport and exercise and am more active than most men my age.
Would I be more apt to get symptoms you suggest on account of low testosterone?

Dr. André Guay: Removing the testicles will lower testosterone and cause symptoms of deficiency. There are other ways of reducing testosterone in men with prostate cancer. There are medications that can do the same as castration and you should discuss this with your urologist.


Topsham, Maine: Dear Dr. Guay:

After reading up on prostate cancer and some of the treatments, do I deduce correctly that persons with low testosterone would have a reduced chance of contracting prostate cancer?

R. Smith

Dr. André Guay: There is a study that showed a decreased risk of prostate cancer in men who purposefully lowered their T levels. This has not been confirmed by another study. Unfortunately these men have an awful lot of sexual side effects. There is also data that suggests that low T may cause a higher malignant form of prostate cancer when it does occur. Lowering testosterone to prevent prostate cancer is currently not recommended.


Moderator: Unfortunately, our hour is up. Thanks, Dr. Guay, for answering our questions. Thank you everyone for joining us.

Dr. André Guay: This has been a thought-provoking experience. I am very impressed with the quantity and quality of the questions that have been submitted. There is clearly a high interest in this field. I encourage more discourse like this and I hope that some of these answers have helped.

Due to time constraints, I was unable to answer all of the great questions. I will make an attempt to answer more of them and answers will be available at the Men's Health Corner at the Alliance for Aging Research's website at www.agingresearch.org. You will also find more information on low T and questions to ask your physician if you think you may have low T.