Online Health Chat with Andy Altman, MD

Thursday, June 30, 2016


Male hypogonadism is defined as the failure of the testes to produce androgen, sperm or both. Although the disorder is exceedingly common, its exact prevalence is uncertain. Signs and symptoms vary according to age. Testosterone production declines with advancing age; 20 percent of men older than 60 years and 30 percent to 40 percent of men older than 80 years have serum testosterone levels that would be considered below average compared to their younger adult male counterparts. During this private, live web chat, Cleveland Clinic urologist, Andy Altman, MD, answered questions about hypogonadism and what the options are for treatment.

About the Speaker

Andy Altman, MD, is a board-certified urologist in the Glickman Urological & Kidney Institute at Cleveland Clinic. Dr. Altman’s specialty interests are general urology, urinary tract stones, BPH, prostate diseases, genitourinary tract cancers, incontinence, men's health and urinary tract infections.

Dr. Altman earned his medical degree from State University of New York at Buffalo in 1995; he had previously completed his undergraduate studies at State University of New York at Geneseo in 1991. He completed his residency at Case Western Reserve University in Cleveland, OH.

The Department of Urology within the Glickman Urological & Kidney Institute is ranked No. 2 in the nation by U. S. News & World Report. Urologists in this institute are also recognized worldwide for excellence in patient care, teaching and research in all aspects of urology.

Let’s Chat About Hypogonadism in the Aging Male

What, How and Why

Seiop: What is hypogonadism and how prevalent is it?

Andy_Altman,_MD: Hypogonadism is a state of low testosterone. In men, this can often be associated with symptoms such as low sexual interest, erectile dysfunction, low energy, depression, and loss of bone and muscle mass. A gradual decrease in testosterone cannot be prevented, as it is a part of normal male aging. However, if the mentioned symptoms are present, and the testosterone is very low, we can offer testosterone replacement therapies.

David: What causes hypogonadism? Is there any way to prevent it?

Andy_Altman,_MD: There are many causes of low testosterone. Often, a man with low testosterone can have more than one cause.

  • Primary hypogonadism is caused by failure of the testicle to make testosterone. Causes can include testicular loss from trauma or infection, medications such as corticosteroids (prednisone, hydrocortisone), chemotherapies for cancer, environmental poisons (BPA in plastics) and many more.
  • Secondary hypogonadism is caused by the brain and/or pituitary gland failing to send the proper chemical signal to the testicles to produce testosterone. Causes include non-cancerous growths of the pituitary gland (pituitary adenoma), brain radiation and some congenital syndromes (Kallman syndrome).

kimtup: Is low T curable, or is this something I will have to manage for the rest of my life? What happens if I stop treatment?

Andy_Altman,_MD: Age-related low testosterone is not preventable or curable. It is also not a disease that requires prevention and cure. It is a normal part of human aging. However, if the levels are low AND you have symptoms, then you might benefit from replacement to bring your levels back into the normal range.

felipe's wife: Why do testosterone levels drop as you age? Is this also like a “male-menopause?”

Andy_Altman,_MD: This is very similar to female menopause, except age-related testosterone decline is gradual and not associated with as dramatic an onset of symptoms. We often refer to symptomatic men as having "andropause." Like menopause, andropause is not a disease. It is a part of the natural human aging process.

loveitaly: In a middle aged man (50+), can the low level of testosterone be compared to the loss of hormones when a woman reaches menopause? Can you clarify the concept that men do go through a male menopause, andropause if I am not mistaken? Usually, men don't agree with this fact. Does severe stress have a role in low T? Thanks for your expertise and time.

Andy_Altman,_MD: I think I touched on this earlier. Men do not go through the more rapid loss of hormones that women do in their 50s, and as a result do not have the more dramatic presentation of symptoms. If a man has low to borderline testosterone and no symptoms, then he need not be treated, and he doesn't have "andropause."

Diagnostic Details

RonnieP: Is testing for low testosterone levels part of an annual physical exam as men age or is it only checked if there are concerns overall?

Andy_Altman,_MD: Routine testing is not done unless a man reports symptoms that could be associated with a low testosterone level. Again, these symptoms include low energy, loss of sexual drive, erectile dysfunction, and loss of bone and muscle mass.

grapevines: At what level or point is someone considered to have low testosterone? How is it measured?

Andy_Altman,_MD: A total testosterone level is measured in the morning (between 8 and 10) because of the natural 24-hour cycle of testosterone levels. If this is low (below 250 to 300), then it is repeated on a different morning along with some other hormone levels to help to better characterize the low testosterone state.

Treatment Tidbits

Frustrated: What treatment options are available for someone with low testosterone?

Andy_Altman,_MD: Some treatment options include:

  • Injections (testosterone cypionate, testosterone enthanate)
  • Patches (Androderm)
  • Topical gels (AndroGel)
  • Injectable pellets (Testopel)

Frustrated: Are there any risks associated with treatment for low T?

Andy_Altman,_MD: Yes. There is an increase in your red blood cell count (called erythrocytosis), which can be a risk factor for blood clot formation. The oral forms of testosterone (pills) can be very toxic to your liver. Testosterone should never be prescribed to anyone with breast cancer (yes, men do get this disease occasionally). Also, men desiring fertility should never take supplemental testosterone, as this will shut down sperm production. Initially, the gels can be transmitted to close contacts such as family members (think young children and partners).

putzer: I just started AndroGel. How long does it take before a noticeable effect?

Andy_Altman,_MD: It depends on the symptom you are concerned about. Give it at least two months. Pay close attention to any changes in your sex drive (libido), erection quality, energy level, strength and endurance, and mood. My guess is that you will have improvements in several areas, but that they will not be sudden or dramatic. Remember, we want to bring your levels into the normal range, not the high range.

totti: In what cases should I avoid testosterone replacement therapy?

Andy_Altman,_MD: Avoid it if you have breast cancer, untreated prostate cancer or are desiring fertility. There is some evidence that testosterone might make sleep apnea worse, so if you have severe sleep apnea, you should probably avoid it.

Individuals Effected

Selene324: Is low testosterone solely limited to aging males? Is there an age range when this may occur?

Andy_Altman,_MD: No. You can have low T at any age depending on the reason. I recently saw a young man (23) with low T following the loss of a testicle from trauma. The reason it is so common in the aging male is because men lose one percent to two percent of their testosterone annually after age 35. By age 70, 45 percent of men have levels that would be considered low for a male in his 20s. Five percent to 10 percent of these older men will have symptoms and will possibly benefit from testosterone replacement.

Kasiam: I know this question is not related necessarily to the “aging male” population, but is there a connection/concern about low testosterone and body building?

Andy_Altman,_MD: If you have low testosterone, you may have a difficult time achieving your bodybuilding goals since testosterone is an important component of building and maintaining muscle mass. Having said that, I do not advise testosterone therapy of any kind unless there truly is an identified cause for low testosterone. In other words, testosterone should not be prescribed to men just because they want to raise a normal testosterone level into the supra-physiologic range just to maximize muscle mass.

Option Pros and Cons

HiddenFox: I have been taking AndroGel at the lowest dose (1.5 percent at two pumps per day) for about 45 days. I am seeing very little effect from this. Does it make sense to check my testosterone level now or should I wait some?

Andy_Altman,_MD: I cannot specifically answer your question and would advise that you ask your treating physician about any dose adjustments. However, there are many benefits from this therapy that you may not realize you are getting. These include an increase in bone density (reduction in hip fracture risk) and lean muscle mass (more strength). Also, an improved sense of well being and vitality can be seen. If you are focusing only on your sexual symptoms, you may be missing these other benefits.

Birdman: What are the advantages of testosterone injections versus other replacement methods such as patches or gels?

Andy_Altman,_MD: The main advantage of injections is that the testosterone cannot be transmitted to your close contacts. This is a real risk with the gels.

linTin: You mentioned in an earlier question that the gels can be transmitted to close contacts such as family members (think young children and partners). Are there specific precautions to avoid this? Is it just a matter of the gel drying --- or the first few weeks or what?

Andy_Altman,_MD: This is always a potential risk, and the treated skin should be kept covered.

Connected Conditions

56789: I've read that men who have had low T for years are at risk of osteoporosis and are more susceptible to bone fractures. Why is that? I thought osteoporosis was more of an issue for women.

Andy_Altman,_MD: That is a fantastic question. Osteoporosis in men is very often overlooked. This is partly because osteoporotic fractures (hip fractures) are more common in women. However, men are actually more likely to die form a hip fracture complication than are women. As such, this is an important issue. Like estrogen, testosterone is an important part of bone turnover and production. A significant and prolonged deficit of testosterone can lead to bone loss and osteoporosis.

monfortab: Does hypogonadism lead to prostate cancer?

Andy_Altman,_MD: No. Prostate cancer is not caused by testosterone or a lack of testosterone. However, prostate cancer is a testosterone sensitive cancer, and we do not treat men with testosterone replacement if they have an untreated prostate cancer.

Vance: Is weight loss associated with an increase in testosterone levels?

Andy_Altman,_MD: This is a great question. Testosterone replacement will make it easier to shed the extra pounds caused by fat. You may, however, gain some weight from muscle. Overall, you should expect easier weight loss and increase in lean muscle mass if you are exercising routinely.

sanibla: I have heard that some men taking testosterone replacement experience mood swings, especially anger. Is this normal?

Andy_Altman,_MD: This can happen if we overshoot the mark on your testosterone levels. Bodybuilders are known to commonly experience "roid rage" because they are self-medicating with the intention to overshoot.

Johncjd: I am unable to achieve an erection. Upon ejaculation, there is very little semen, and sometimes there is no semen. Would you give me an opinion if this is abnormal? I am in my mid-60s.

Andy_Altman,_MD: Erectile dysfunction is commonly associated with low testosterone. However, there are many reasons to have erectile dysfunction beyond low testosterone. Your ejaculation concern could also have several causes other than low T. I would advise making an appointment with a urologist to evaluate both concerns in more detail.


Moderator: That is all the time we have for questions today. Thank you, Dr. Altman, for taking time to educate us about common hypogonadism in the aging male.

Andy_Altman,_MD: Thank you everyone for your excellent questions. I really enjoyed this. I have to get back to my patients now. Have a nice day.

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Cleveland Clinic

The Department of Urology within the Glickman Urological & Kidney Institute is ranked No. 2 in the nation by U. S. News & World Report. Urologists in this institute are also recognized worldwide for excellence in patient care, teaching and research in all aspects of urology.

Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for hypogonadism in the aging male.

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