The rules and regulations for obtaining subsidized a testosterone replacement via the PBS (Pharmaceutical Benefits Scheme) have recently changed, which is likely to mean that many men will have to pay a lot more to have these treatments.
The cut-off level for having testosterone replacement treatment is now a testosterone of <6 (previously <8), and in addition patients have to see a specialist to get treatment on the PBS, rather than just their GP. For full details see here.
The facts about testosterone replacement and hormone therapy.
Men experience a gradual fall in testosterone levels from early adulthood onwards.
Testosterone deficiency should only be diagnosed if there are repeatedly low testosterone levels and relevant symptoms, which may include:
- Reduced libido
- Decreased spontaneous erections
- Loss of body hair, reduced need for shaving
- Small or shrinking testicles
- Hot flushes and breast discomfort
- Fatigue or low mood (one of many causes of this!)
- Should be taken between 0800 and 1000; levels vary widely depending on time of day, food intake and other factors, therefore repeated measurements may be required – a diagnosis should not be made from a single sample
- The cut-off level for an abnormal testosterone is not universally agreed; but in practice a level of >12 is OK, 8-12 along with symptoms or signs is borderline, and 4 without further evaluation) and a DRE (Digital Rectal Examination, checking for the size of the prostate)
- If consistently borderline, a measurement of free (versus total) testosterone may help to clarify (men with obesity and diabetes often have a low SHBG (Sex-Hormone Binding Globulin) – which gives rise to a lower total testosterone but normal free testosterone)
- Testosterone replacement may be effective in some men with a deficiency, but requires evaluation and discussion with your GP on an individual basis.
Blood test diagnosis:
- If a low testosterone level has been found on multiple occasions, your doctor may perform additional tests (prolactin, LH and FSH levels) to establish whether there are any problems with your hypothalamus or pituitary glands (in the brain; control the production of multiple hormones in the body)
- You should also have a blood test checkup (glucose, cholesterol, kidney and liver function, iron levels
- If testosterone therapy is contemplated, men should have their PSA performed (Prostate Specific Antigen – should not start testosterone if >4 without further evaluation) and a DRE (Digital Rectal Examination, checking for the size of the prostate)
Testosterone production is suppressed by many conditions, including:
- Metabolic syndrome – obesity, insulin resistance. Fat tends to convert testosterone to oestrogen.
- Type 2 Diabetes
- Chronic kidney disease
- Drugs / Medications, especially corticosteroids (e.g. prednisolone) or narcotics
- Anabolic steroids
- Should only be contemplated once you have been fully assessed, in order to rule out causes which require treatment in their own right
- The long term risks and/or benefits of “late onset” low testosterone are not well understood due to the lack of large, long-term trials
- In men with reduced testosterone secondary to other illnesses, the focus should be on lifestyle measures, such as weight loss – 10% weight loss can achieve an increased testosterone of 2-3 nmol/l; higher levels of weight loss (e.g. bariatric surgery, gastric lap band) can increase testosterone levels still further.
- If benefit is going to be found, it is likely to occur within 3-6 months; therefore if no benefit, there is unlikely to be any reason to continue longer than that.
Testosterone deficiency and erectile dysfunction:
- These are two separate, but overlapping conditions
- A recent trial found no benefit in adding testosterone to a drug in the “Viagra” class (however these male subjects were not all low in testosterone)
- Needs to be considered on a case-by-case basis
Risks of testosterone therapy:
- There is no long term evidence that testosterone therapy causes prostate cancer (but because of increased monitoring of the prostate, there may be an increased risk of over-diagnosing pre-existing, clinically insignificant prostate cancer – see my PSA blog)
- Testosterone therapy may cause growth of prostate cancer that has already spread (hence the need for pre-treatment PSA and ongoing monitoring)
- Possibly can worsen heart disease in those who already have this
- Lack of long term data – we don’t know for sure how safe or risk testosterone therapy is.