Testosterone deficiency

Testosterone deficiency – low testosterone levels in men – happens when your body can’t make enough testosterone. It’s also called hypogonadism.

Testosterone is the most important sex hormone in men. Your brain and your testicles (testes or male gonads) play a role in the production of testosterone. Your body starts producing testosterone during puberty and levels of the hormone start decreasing from about the age of 30 years onwards.

The hypothalamus and pituitary gland in your brain make the hormones that stimulate your testicles to make testosterone.

Low testosterone can have a significant impact on your health and how you feel, as testosterone is important for maintaining the characteristics that make you look and feel like a man. It also has a role in sexual function.

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Common symptoms

• Low libido (low sex drive).
• Erectile dysfunction.
• Enlarged or painful breasts (gynaecomastia).
• Fertility problems (inability to father children).

Uncommon or vague symptoms

• Reduced testicle size.
• Reduced energy or mood.
• Decreased muscle mass and strength.
• Less body hair.
• Bones that are easily broken.
• Hot flushes and night sweats.

If you have a pituitary tumour or pituitary disease you may have vision problems, double vision or headaches.

If testosterone deficiency develops before puberty it may also cause:

• delayed onset of puberty
• lack of deepening of the voice
• reduced growth of the penis and testicles
• excessive growth of the arms and legs compared with the trunk of the body.

Low testosterone can be due to problems within your testicles or elsewhere in your body. Sometimes the cause isn’t known.

Some of the causes of low testosterone in men include:

• trauma to your testicles, eg, football injury or torsion,
• infection, eg, HIV/AIDS or mumps orchitis (inflammation of the testicle due to mumps infection)
• radiation or chemotherapy treatment for cancer
• some medications, such as opiate painkillers and corticosteroids (eg, steroid injections)
• hormone disorders (eg, pituitary tumours or diseases, high levels of prolactin).

Low testosterone levels are also associated with:

• chronic diseases, such as liver and heart disease
• obesity
• sleep disorders eg, obstructive sleep apnoea, sleep deprivation
• type 2 diabetes
• excessive alcohol consumption
• some genetic conditions (eg, Klinefelter syndrome, haemochromatosis, Kallmann syndrome)
• misuse of anabolic steroids
• emotional stress.

The diagnosis of testosterone deficiency is based on your history, symptoms, a physical examination looking for signs of low testosterone (such as body hair changes, swollen breast tissue and testicular size) and blood tests.

If your doctor discovers that you have a low testosterone level, the first step is to confirm it with a second blood test. Further tests are then needed to work out the cause of your low testosterone level. Testosterone levels should be tested in the morning before 9 am. 

It can be difficult to diagnose testosterone deficiency, especially in older men because testosterone levels naturally fall with age.

A low testosterone level by itself (that is, without any symptoms) doesn't need treatment. Testosterone replacement therapy (TRT) can have side effects, and the risks of long-term testosterone treatment aren’t well known – particularly in relation to prostate cancer, heart disease, and stroke risk.

You will only be considered for TRT if you have clear symptoms of low testosterone and blood test results that confirm it. If your testosterone levels are low but in the normal range you are unlikely to be treated with TRT.

Since testosterone levels normally fall as men get older, the risks of testosterone replacement may outweigh the benefits for older men with levels that are slowly falling over time. Read more about testosterone replacement therapy.

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Any underlying cause of testosterone deficiency should be treated and lifestyle factors that may be contributing should also be addressed (see below). If your doctor thinks you may have a pituitary tumour or disease, they will refer you to an endocrinologist who is a doctor that specialises in the treatment of hormone-related conditions.

Close follow up is needed with your doctor. Blood tests are done every few months to monitor your testosterone levels and blood count. Sometimes other tests are done, such as monitoring PSA (prostate specific antigen) levels.

The following lifestyle changes can help to maintain a healthy level of testosterone:

• Lose weight if you are overweight.
• Keep active and exercise regularly.
• Get enough sleep (at least 7 hours per night).
• Don't drink too much alcohol.
• Reduce stress.

You should also talk to your healthcare provider about making sure that chronic conditions, such as sleep apnoea, type 2 diabetes or obesity, are well managed as this will help to improve your testosterone level.

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