The purpose of this article is to review the data on LOH, also known as low T, and present the most recent evidence and recommendations regarding the approach to the patient from our case scenario. A 56-year-old overweight man with symptoms of low energy, daytime sleepiness, and decreased libido happens to be watching a golf tournament on TV from his favorite recliner and suddenly a commercial appears. Other studies found that the decline in testosterone with age might be more related to comorbidities that develop in many aging men. Because this study was carried out in one of the nation's largest commercially insured populations, these findings have a high degree of statistical power and are likely to be representative of other commercially insured populations across the U.S. Despite these limitations, we believe this study has important strengths, including a large sample size, representation of all U.S. geographic regions, access to detailed laboratory data, and inclusion of a broad age range. Third, information on the physician who prescribed the medication was not available in this data source, and we were unable to determine whether or not patients who were seen by an endocrinologist or urologist were prescribed testosterone by another provider. Moreover, our data would not have captured testosterone laboratory tests that were conducted at a Veterans Affairs clinic or a commercial testosterone clinic. We also reported that 39.3% of new testosterone users did not have a serum PSA test conducted in the 12 months before treatment, and 56.7% did not have this test conducted in the 12 months following treatment. It is unclear why such a large percentage of patients failed to receive the recommended testosterone assessment either before or after initiating treatment. An increase in PSA of more than 1.4 ng/mL within a 12-month period of testosterone treatment or an International Prostate Symptom Score above 19 should prompt urological evaluation. The different testosterone preparations available include intramuscular formulations, topical gels, solutions, and skin patches. For this reason, all men should be assessed for risk of breast and prostate cancer prior to treatment. Let’s get into how you can recognize the signs of high T levels in people with penises and people with vulvas, how it’s diagnosed, and what to do about it. T typically occurs in much higher levels in people with penises, but it’s also present in the bodies of people with vulvas in much lower concentrations. A doctor can help determine the best course of treatment, which may include medications and lifestyle changes. It is known that testosterone stimulates bone marrow production of erythrocytes, which might result in an increased hematocrit in some men, and therefore this should be checked at the same time as the PSA level.2,3 Examination of the prostate should be performed routinely, although the exact frequency after initiation of testosterone replacement is still debatable. Therefore, additional studies are needed to understand how masturbation frequency may affect testosterone levels in the long run for all people. Though some people believe that masturbating can decrease testosterone levels, there isn’t any evidence to support this. Changes in your sexual health could be a sign of abnormal T levels. Changes in hair growth — including excess body hair growth or balding — are also common with excess testosterone levels. For people with a vulva, high testosterone levels can lead to an irregular menstrual cycle, increased muscle mass, or an enlarged clitoris. In some cases, high testosterone levels can cause mood changes, including increased irritability or aggression. Androgen rise has been found to be greater in those patients who lose more weight (14, 15). Such issues include use of corticosteroids or opiates, malnutrition, acute illness, alcoholism, and cirrhosis (5, 11, 12). Additionally, at this point it is prudent to consider outside influences on sex hormone production and address these issues first if appropriate. Ultradian fluctuations (rhythmic fluctuations of less than a 24-hour period but more than 1 hour) are more pronounced in older men, while circadian variation in testosterone is blunted, but still present, in older men (12). The most common cutoff transitioning from normal to low ranges from 280 ng/dL to 320 ng/dL; the guidelines recommend using 300 ng/dL as the cutoff (11). Testicular volume may be decreased (normal volume 15 to 30 mL, equivalent to the size of a quarter dollar coin). Typical exam or diagnostic findings include obesity, loss of body hair, gynecomastia, mild anemia, and osteoporosis.
