“I’m just tired all the time.” “My wife tells me I’m getting grouchy.” “I’m exercising but am gaining weight and losing muscle tone.” “My motivation is gone.”

These are common complaints of men with low testosterone levels. Everybody thinks testosterone is only about sexual function and if “that” is still working, testosterone can’t be low. True, some men with low testosterone may experience low libido or erectile difficulties. But there’s much more to the story.

Testosterone is an important biological messenger and affects nearly every aspect of a man’s physiology. If the level is too low for an individual’s needs, nothing works quite right. Sleep patterns may be altered, with fewer REM cycles, leading to less restorative sleep. Because of this, many men with low testosterone complain of fatigue that does not resolve with sleep. The lack of quality sleep can affect mood, causing a man to feel depressed and irritable. Many men with low testosterone report a lack of motivation toward life in general. They know what they should be accomplishing, but find it very difficult to get moving in the right direction or to finish tasks.

Testosterone is important for protein synthesis and tissue building and repair. If the level of testosterone is low for a person’s needs, he can notice thinning of the skin, decrease in muscle size, tone and strength and even a decrease in bone strength over time. A man with low testosterone may have a harder time recovering from exercise or injuries. He may also notice he doesn’t see progress with exercise like he used to and exercise may seem more tiring.

Below are some concepts important in understanding how testosterone works.

Total Testosterone   This is all the testosterone you have on board. Think of a bucket full of testosterone.

Sex Hormone Binding Globulin (SHBG)  This is a protein that binds up to some of that testosterone in the bucket, causing that part of the Total Testosterone to be unusable. 

Free Testosterone   This is the testosterone in that bucket that is not bound up to the protein, so we call it ‘free’. Free testosterone is what your body has access to and can use.

So you see how the Total Testosterone level doesn’t tell the whole story. You can have a high Total Testosterone, but if you have a lot of SHBG you may not have very much Free Testosterone and may have all the symptoms of low testosterone. The point is don’t fixate on your Total Testosterone number; there’s more to the picture than that. With hormone therapy, it’s all about balance and finding that minimum dose that works well for you.

Speaking of balance, if we’re talking testosterone, we also have to talk estrogen. In human tissue there is an enzyme called aromatase. It’s job is to turn some of your testosterone into estrogen.  It’s actually important for men to have a little estrogen because it contributes to good brain health, good bone health and libido among other things. Most men do well with an estrogen level somewhere in the 30’s, receiving the benefits of estrogen without negative affects. 

Some men have stronger aromatase activity, changing more of their testosterone into estrogen than they need. If a man has too much estrogen, he may gain weight easily and or he might notice tenderness and tissue development in the breast area or he might become more irritable or all of the above.  Too much estrogen for too long may contribute to prostate enlargement. Some men may be very sensitive to estrogen and have symptoms of excess even when it measures in the 30’s. Some men can tolerate levels in the 40’s with no symptoms. Everyone is unique, which is why we measure estrogen levels from time to time to monitor this. If a man makes too much estrogen, we can use simple therapies to help him metabolize the estrogen more effectively or to slow down the aromatase activity.

Another important measure is hematocrit, which is a marker for red blood cell production. On testosterone replacement therapy, a man can make more red blood cells. While this is only a slight increase for most men and can help with aerobic endurance, some men may make too many. Too many red blood cells thicken the blood, which could lead to blood clots and possibly heart attack or stroke. It’s important to monitor hematocrit regularly and more often in men we identify as having increased production. If the hematocrit level creeps up, donating blood or having therapeutic phlebotomy can keep this under control.

So, you get the picture that there’s more to Testosterone replacement than just giving you a shot. The information above covers some of the basic concepts important to understand while on therapy. Testing to monitor your progress occurs on a regular schedule, but we can spot check anything at any time if needed. Our goal is to keep you healthy, safe, feeling good and living your optimal life.