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Low Testosterone and How it is Diagnosed

by Chris Steidle, MD

Low testosterone or andropause can be complicated to diagnose. A list of symptoms of low testosterone that you share with your doctor can play a major role in helping both of you decide if testosteronereplacement therapy should be considered.

Symptoms of low testosterone or normal aging?

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Many of the symptoms described as andropause have long been associated with normal aging. Still other symptoms in this list may be attributed to lifestyle problems (excessive alcohol intake, especially beer), poor nutrition, use of certain medications, insufficient exercise or inactivity due to arthritis or injuries, problems with the nervous system, chronic illnesses and even genetic makeup. So, how can you and your doctor decide whether testosterone supplements might help?

Low testosterone quiz or questionnaire

The best place to begin the diagnosis is with a questionnaire that you can take by yourself. There are several available but the most commonly used one is called the ADAM (Androgen Deficiency in Aging Men) questionnaire. It consists of ten questions and if a man answers certain questions with a yes or answers any three others with a yes, he can suspect that a low testosterone level may be causing some of his problems.

If you would like to answer the questions on the ADAM questionnaire for yourself, click on ADAM.

You might also want to take the AMS Questionnaire (Aging Male Symptom rating), which allows you to measure symptoms in three different areas, mental, physical and sexual, as well as keep track of changes over time. In fact, if you register at the Andropause Center, you can return once a month or so and retake the AMS questionnaire. This will help you to see how your symptoms are changing as you make changes to your lifestyle or increase your testosterone levels with supplements.

Just because you have a positive score on the ADAM, AMS (or any) questionnaire does not mean that you have low testosterone or andropause, but it probably indicates that a visit to your doctor is a good idea. Most family physicians or general practitioners should be able to diagnose the syndrome but, certainly, a urologist or an endocrinologist would know the best type of examination to conduct.

Steps for diagnosing low testosterone

Regardless of the physician's training, there are certain steps and tests that are standard for diagnosing low testosterone or andropause.

Diagnose low testosterone with a medical history and physical examination

In spite of amazing medical advances, one of the most important diagnostic tools is the information a patient provides a doctor in the form of a medical history. Your participation in providing as complete information as you can will be important in this diagnosis. At the first visit, a doctor will ask many questions about general health as well as specific questions about sexual interest and activity that relate to low testosterone. Some of the specific topics asked about may include:

Personal History:

  • Date of birth
  • Blood Type
  • Allergies
  • All prescription and non-prescription drugs currently being taken
  • Dates of immunizations
  • Previous and existing conditions and major illnesses
  • Names of current and previous doctors
  • Dates/reasons for previous medical visits
  • Dates and kinds of surgeries
  • Copies of past test results
  • Lifestyle habits - smoking, alcohol consumption
  • Family and relationship problems, including any sexual ones
  • Major life events or changes that have occurred

Family History:

  • Alcoholism
  • Blood diseases (hemophilia or sickle cell)
  • Cancer (all types)
  • Diabetes
  • Heart disease, hypertension or stroke
  • Kidney disease
  • Mental illness
  • Other illnesses and disorders

Before your doctor's appointment, you may find it helpful to make a list of your parents, siblings, aunts, uncles and grandparents, with age at death and its cause, or existing conditions and age if the person is still alive. This information will help the doctor identify potential genetic tendencies in your family.

Your doctor will also ask you questions about your sexual history and development. These may include:

  • Any genital abnormalities present from birth
  • When and how quickly puberty took place
  • Current status of sexual function
  • Status of secondary sexual characteristics such as beard growth, muscular strength and energy level
  • Rate of nocturnal emissions
  • Degree of penile rigidity during erections
  • Frequency of sexual thoughts, desires and fantasies
  • Frequency of masturbation or sexual intercourse

Once the doctor has a general idea about your past and current situation, he will conduct a thorough physical examination. In addition to a typical exam that includes blood pressure, heart rate and other basic measures, the doctor will look at the amount and distribution of body hair, presence and degree of breast enlargement, size and consistency of the testes, abnormalities in the scrotum, and the size of the penis.

Once you and your doctor decide that treatment with supplemental testosteroneis indicated, the doctor should perform further tests to rule out prostate cancer including a digital rectal exam and prostate specific antigen (PSA) level. These tests should be repeated at 6 weeks, 3 months, 6 months and annually thereafter. Monitoring your health while on treatment is very important.

Blood Tests to determine testosterone level

The most obvious test required is a measurement of testosterone level in your blood. The test for total testosterone has been widely available for many years but, as discussed elsewhere, is not a very reliable measure of how much testosterone is actually "free" and available to the cells.There are few reliable and affordable tests currently available for free testosterone.

Another test available is for SHBG. By running a test for total testosterone and another for SHBG, your doctor can use these values to calculate the amount of free testosterone in the blood. This is done by dividing the total testosterone value by the value of the SHBG and multiplying by 100 to arrive at a percentage value called the free androgen index. In normal men, this value should stay between 70 to 100 percent, but in andropausal men, it may fall to below 50 percent. In any event, measurement of total testosterone is probably the most widely available and utilized test today. In the United States at present, it also remains the standard for indicating a need for replacement therapy.

Normal testosterone level

When to take the blood sample for these tests is important because the level of testosterone normally varies from a high point in the morning to lower points throughout the day. The blood sample should be drawn between 8:00 and 9:00 AM to be sure it will provide the highest level of testosterone during the cycle. The normal range for total testosterone is 300 - 1000 ng/dl.

If the testosterone level determined through a blood test is found to be extremely low and your doctor feels that developing an exact clinical diagnosis is important based on the physical exam and patient history, blood tests for FSH, LH and/or prolactin may be ordered. Results of these tests can provide a more complete picture of a man's hormonal status.

Other tests may be indicated by the medical history or physical exam. For example, a doctor may order bone density testing if bone loss is suspected, or genetic testing may be useful to confirm an inherited condition. If tests indicate that there might be a problem with the pituitary gland, the doctor may want to examine the gland itself through a computed tomography (CT) scan or magnetic resonance imaging (MRI.)

In any case, these tests are chosen to augment an andropause diagnosis. If their results are all normal but a group of symptoms strongly indicates that you have the andropause syndrome, you should be allowed a short trial of at least three months of supplemental testosteroneto see if it makes you feel better. Before undertaking such a trial, you and your doctor will want to discuss the potential risks associated with this treatment and measure them against potential improvements in feelings and lifestyle.

You may also want to try basic lifestyle changes if your symptoms appear to be directly related to smoking, drinking, overweight or stress. For help and support to make these changes, visit our Wellness Center with Don Ardell.


References

Brawer, Michael K., MD. Androgen Supplementation and Prostate Cancer Risk: Strategies for Pretherapy Assessment and Monitoring. Rev.Urol. 2003;5 (suppl 1):S29-S33.

Caruthers, Malcolm, MD. The Testosterone Revolution. London: Thorsons; 2001.

Heaton, Jeremy, P.W., MD. Hormone Treatments and Preventive Strategies in the Aging Male: Whom and When to Treat? Rev.Urol. 2003;5(suppl 1):S16-S21.

Matsumoto, Alvin M., MD. Fundamental Aspects of Hypogonadism in the Aging Male. Rev.Urol. 2003;5(suppl 1):S3-S10.

McCulloch, Andrew, MD. Case Scenarios in Androgen Deficiency. Rev.Urol. 2003;5(suppl 1):S41-S48.

Nieschlag, E., Behre, H.M., Nieschlag, S. Testosterone: Action, Deficiency, Substitution. Berlin: 1998.

Steidle, Christopher P., MD. New Advances in the Treatment of Hypogonadism in the Aging Male. Rev.Urol. 2003;5(suppl 1):S34-S40.

Notes

1. Matsumoto, Alvin M. Fundamental Aspects of Hypogonadism in the Aging Male. Urology. Vol. 5, Supplement 1. 2003;S3-10.
2. Morley, JE. J Gend Specif Med. 2001;4:49-53.

Posted February 2004
Updated March 2013

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