The focus of this podcast is to clearly articulate the need to address underlying lifestyle factors that impact males across the lifecourse and contribute to the burden of chronic disease. There are increasing pressures on medical practitioners to prescribe medications to address issues that need to be addressed first and foremost through health behaviour change.
Men are bombarded with advertisements and articles about testosterone’s benefits and how to boost their levels, and it’s long been pushed as a cure-all for a range of men’s health issues including everything from sex drive to strength. It’s particularly pushed on ageing men with myths around ‘male menopause’ or ‘andropause’ causing a drop in testosterone that should be solved with testosterone replacement therapy. This isn’t the case, but there are important lifestyle factors and health conditions that can influence testosterone level in men, and serve as an indication of their overall health.
Levels in males peak during adolescence and early adulthood. As men age there may be a small, gradual drop in testosterone, but this is often because of the development of chronic conditions, such as obesity or diabetes* that develop due the impact of poor health behaviours and lifestyle choices (alongside genetic factors for some). Being overweight and carrying weight around your waist is linked to lower testosterone levels**.
Whilst weight loss can help increase testosterone, adopting healthy behaviours is likely to positively impact health and wellbeing with or without weight loss. Healthy older men with normal body weight usually do not experience a significant drop in testosterone levels in their blood, and there is no such thing as ‘male menopause’ or ‘andropause’.
The most important thing to do when a patient first presents is take a thorough history of all the signs and symptoms that are presenting. It is most important to address the underlying cause of these conditions.
When investigating the endocrine system it is important to consider the feedback loops and assess all parts of the loop. A reference range is used as a guide by testing laboratories and doctors to decide whether a person’s hormone levels are normal or low, and whether treatment may be needed. When assessing the HPG-axis, the GP should refer the male for blood tests, including testosterone, luteinising hormone, follicle-stimulating hormone and prolactin along with assessment of thyroid function and iron levels.
There are common and important conditions that feature androgen deficiency, and every effort must be to detect and assist these men. The leading example is Klinefelter syndrome – a condition in which you’re born with an extra X chromosome that affects around one in 600 men. It's significantly underdiagnosed with less than half of men with Klinefelter syndrome found across their lives.
The ‘normal’ testosterone reference range for healthy, young adult men extends across a wide range and may vary from 8 up to 30 nM. Most healthy people (95%) have hormone levels that fall within a standard reference range for their sex. However, a few healthy people (5%) have levels below the range. Due to this wide variability it needs to be understood that for some normal men, a morning level of 8 nM is their ideal level and does not mean they have androgen deficiency. This is why the diagnosis of androgen deficiency is not based on a simple blood test but includes a number of assessments, including a full medical history, physical examination and other tests.
Higher testosterone isn’t necessarily healthier. Professor Robert McLachlan, Medical Director, Healthy Male says, ‘One healthy man can have a level of eight and be completely and utterly healthy or another man may sit with a level of 28 and be equally unhealthy — those numbers are right for that man. It's not like the guy who's on 28nM is on too much or the guy that's on a level of eight is on too little, because that's where his body is set to. You can think of it like height — perfectly healthy men can be 165cm or 205 cm, it’s just where you sit on the reference range.’
Artificially high testosterone levels through inappropriate use of testosterone (commonly referred to as androgen abuse) can cause a variety of health problems, including cardiovascular disease, infertility and an increased risk of death.
* Frederick C. W. Wu, Abdelouahid Tajar, Stephen R. Pye, Alan J. Silman, Joseph D. Finn, Terence W. O'Neill, Gyorgy Bartfai, Felipe Casanueva, Gianni Forti, Aleksander Giwercman, Ilpo T. Huhtaniemi, Krzysztof Kula, Margus Punab, Steven Boonen, Dirk Vanderschueren. 2008. The European Male Aging Study Group, Hypothalamic-Pituitary-Testicular Axis Disruptions in Older Men Are Differentially Linked to Age and Modifiable Risk Factors: The European Male Aging Study, The Journal of Clinical Endocrinology & Metabolism https://doi.org/10.1210/jc.2007-1972
** Svartberg, J., von Mühlen, D., Sundsfjord, J., & Jorde, R. (2004). Waist circumference and testosterone levels in community dwelling men. The Tromsø study. European journal of epidemiology. https://doi.org/10.1023/b:ejep.0000036809.30558.8f
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Gary Wittert is a graduate of the University of the Witwatersrand in Johannesburg South Africa. He trained as an Endocrinologist in Christchurch, New Zealand followed by postdoctoral training at Boston Children’s Hospital and Oregon Health Sciences University. He is currently Professor of Medicine and Director of the Freemasons Centre for Male Health and Wellbeing, University of Adelaide and South Australian Health and Medical Research Institute (SAHMRI), Senior Consultant Endocrinologist Royal Adelaide Hospital, and Senior Principal Research Fellow at SAHMRI. He is a Fellow of the Australian Academy of Health and Medical Sciences. His research relating to obesity and chronic disease, funded by NHMRC, ARC, NHF, and the Freemasons Foundation, has generated over 450 research publications, book chapters and expert reports.