Diagnosing Testosterone Deficiency

The diagnosis of testosterone deficiency is a combination of both clinical features and serum measures – neither in isolation is consistently reliable.

Biochemical Evaluation

The measurement of testosterone levels in the blood provides a snapshot of what the the status of the person’s hormone at the time of taking blood.

The secretion of this hormone follows a diurnal rhythm in males; it rises and falls over a 24 hour period. The production occurs during the night and early morning with levels highest when waking up. Serum levels slowly decrease during the day and are lowest in the late afternoon and early evening.

Therefore blood samples should preferably be taken in the morning, when hormones levels are at their highest. Individual variations in serum testosterone levels can occur due to time of day, medication usage, stress, illness or recent surgery.

The testes do not store testosterone. Once produced, this hormone is secreted into the blood stream where it is rapidly adhered to by the protein sex-hormone binding globulin (SHBG).

SHBG is a transporter protein found in the blood. It acts as a carrier to move hormones around the body. Up to 99% of testosterone produced is bound to SHBG. This hormone, to which SHBG does not attach is the biologically available testosterone that is free to act on and enter into cells throughout the body. This “bio-available” hormone is crucial in determining how well it can work in the body.

Some doctors will measure only levels of this hormone (called total testosterone) and not take into account the SHBG levels. While not technically wrong total measurement alone is not the most accurate representation of how much testosterone is free to act in the body. As a consequence the total testosterone reference ranges commonly adopted by pathology laboratories for determination of “normal” and “low” level of this hormone are potentially misleading, especially in the determination of late-onset hypogonadism because the results do not take into account the effects of SHBG. SHBG is elevated with ageing, smoking, high alcohol intake, insulin, oral estrogens and some medications.

In order to establish an accurate diagnosis for a patient it is essential to measure the “free androgen index” or FAI. This is calculated by the total testosterone level in the blood divided by the SHBG level multiplied by 100.

Pathology labs will automatically do this calculation and the result will be the FAI reading. Generally a FAI reading of 70 or less is a cause for concern and a reading below 50 may be a strong indication that testosterone supplementation is warranted. Other factors such as pre-existing illnesses, physical, hormonal, psychological and mental health must be taken into account by the doctor before routine prescribing of testosterone.

Clinical Features

Whether due to testicular, brain, or ageing, the signs and symptoms as a result of the androgen deficiency are consistent.

Individuals may exhibit some or all of the following:

  • Frequent changes in mood (fatigue, depression, anger)
  • Decreased body hair (feminization)
  • Decreased bone mineral density and possible resulting osteoporosis
  • Decreased lean body mass and muscle strength
  • Decreased libido and erectile quality
  • Increased abdominal fat
  • Rudimentary breast development (man boobs)
  • Low or zero sperm in the semen.

The diagnosis of hypogonadism can be facilitated through the use of the AMS (Aging Males’ Symptoms) rating scale.

Once it has been determined that an individual has this kind of hormone deficiency through biochemical and clinical assessment testosterone replacement therapy (TRT) can be considered.

It is imperative that prostate or breast cancer be excluded prior to initiating TRT.

To exclude prostate cancer a doctor will conduct an examination of the prostate gland. This is done via insertion of the doctor’s finger into the rectum of the patient and feeling the size and hardness of the prostate gland. This technique is called a digital rectal examination (DRE) and doctors are well trained in this technique. Also a blood test to measure a component in the blood called serum prostate-specific antigen (PSA) is conducted. Both these tests should be conducted prior to commencing testosterone therapy and are mandatory in men over the age of 40 years.

Research figures show that more than half of all men over the age of 50 suffer from BPH or Benign Prostatic Hypertrophy, a condition characterized by an enlarge prostate. This condition can lead to all kinds of unwanted symptoms such as difficulty urinating and frequent or nighttime urination. The larger the prostate gets, the more it will block the urinary tract and drastically worsen the initial symptoms over the course of only a few years. Generic Avodart (Dutasteride) can help shrink the prostate, relieve BPH-related symptoms and reduce the risk of complete urinary retention or even surgery. As an added bonus, Generic Avodart (Dutasteride) may also help with hair growth in patients who suffer from male pattern baldness.

Roughly 50% of all men develop the first signs of BPH (Benign Prostatic Hyperplasia) by the age of 50. Half of those men then go on to develop the full-blown disease and suffer through much pain and discomfort. Generic Proscar (Finasteride) helps treat and control BPH by shrinking the enlarged prostate, improving urinary flow and treating various other symptoms associated with the disease. Moreover, Generic Proscar (Finasteride) may make surgery unnecessary and can also be used as a preventative measure against prostate cancer.

Generic Flomax (Tamsulosin) is a selective Alpha Blocker for men who have difficulty urinating due to BPH (Benign Prostatic Hyperplasia). Generic Flomax (Tamsulosin) helps by relaxing the veins and arteries so blood can more easily pass through, while at the same time loosening the muscles in the prostate to fascilitate urination.