If you are a man struggling with low libido, decreased energy levels, or fluctuations in mood, you may have a hormone imbalance. Hormones are your body's messengers that tell organs what to do and when to do it. One of the primary hormones in men is testosterone, a hormone critical for sexual function and masculine features. In the testosterone cycle, signals from the hypothalamus in the brain are sent to the pituitary gland, which in turn triggers the testes to produce testosterone. Ninety-five percent of testosterone is produced within the testes, with an additional small percentage produced by the adrenal glands. Research demonstrates that testosterone plays a crucial role in metabolism, vasculature, and brain function, in addition to its well-known effects on bone and body composition.
Male hypogonadism, the medical term for low testosterone levels, can lead to various symptoms. Approximately 40% of men over the age of 45 are hypogonadal. Because hormones play such significant and complex roles in controlling multiple bodily functions, a slight imbalance significantly impacts symptoms. The natural decline of testosterone that occurs with age can be accelerated through dietary choices, poor lifestyle habits, medication exposures, lack of physical activity, and increased stress.
An Integrative Medicine Approach to Low Testosterone in men includes evaluating genetics, diet, hormonal shifts, and other lifestyle habits to determine the root cause and potential treatments. By incorporating in-depth bloodwork and specialty lab testing to get the proper diagnosis treatment, many patients can have a long-term improvement in symptoms.
Low Male Testosterone Signs & Symptoms
Hypogonadism is characterized by serum testosterone levels < 300 ng/dL in combination with at least one clinical sign or symptom:
Signs of Hypogonadism Include:
- Absence or regression of secondary sex characteristics
- Anemia
- Muscle wasting
- Reduced bone mass or bone mineral density
- Oligospermia
- Abdominal adiposity
Symptoms of Post-Pubescent Hypogonadism Include Sexual Dysfunction Symptoms Such As:
- Erectile dysfunction
- Reduced libido
- Diminished penile sensation
- Difficulty attaining orgasm
- Reduced ejaculate
Other Symptoms Can Include:
- Reduced energy and stamina
- Depressed mood
- Increased irritability
- Difficulty concentrating
- Changes in cholesterol levels
- Anemia
- Osteoporosis
- Hot flushes
Of the hypogonadal symptoms evaluated with the Aging Male (ADAM) questionnaire developed in 2000, "lack of energy" appears to be the most important symptom that predicted a low testosterone level in the under 40 population as opposed to decreased libido and erectile dysfunction, which were more frequent in the elderly population.
Low Male Testosterone Possible Causes
There are two main causes of low testosterone in men: primary hypogonadism and secondary hypogonadism.
Primary Hypogonadism
Testosterone levels decline naturally with age and are the highest at puberty (as the male body develops) and continue to decline 1-2% every year after 30 years old. Primary hypogonadism originates from a problem with the testicles. Common causes include Klinefelter's Syndrome, undescended testicles, hemochromatosis, testicular injury, chemotherapy, radiation, and aging.
Secondary Hypogonadism
In secondary hypogonadism, the testicles are normal but function improperly due to a problem with the pituitary or hypothalamus. Testosterone decline can be accelerated through poor lifestyle habits, dietary choices, medication exposures, lack of exercise, chemicals, heavy metals, and increased stress.
Obesity
There is a relationship between excess fat and lower testosterone. Adiposity suppresses the production of testosterone.
Medications
ketoconazole, cimetidine, glucocorticoids, and opioids have been demonstrated to lower testosterone levels
Vitamin D Levels
Low and High levels of Vitamin D are associated with hypogonadism. A study of 225 middle-aged men determined that men with very low levels (≤43.9 nmol/L) and very high 25(OH)D levels (>102 nmol/L) were at increased risk of hypogonadism, indicating a U-shaped association of vitamin D levels and hypogonadism.
Processed Sugar
Sugar can turn off genes responsible for regulating testosterone and estrogen in both men and women, leading to imbalances of these essential sex hormones. This discovery reinforces public health advice to eat complex carbohydrates and avoid processed refined sugar.
Zinc
Adequate zinc intake is associated with optimal production and regulation of testosterone.
Lifestyle
Smoking and chronic alcohol use lower testosterone levels
Thyroid
Hypothyroidism and serum TSH levels below 10 mIU/L are associated with a reduction in serum testosterone levels in males.
Stress-Induced Hypogonadism
Stress increases cortisol and decreases testosterone in response to stress. For example, low serum testosterone levels have been reported during psychological stress, physical stress, and actual stress (such as surgery).
Gut Microbiome Imbalances
A new study correlates gut bacteria with male testosterone levels. This study showed blood levels of testosterone positively correlated with the number of bacteria in the gut independent of other factors such as age, body mass index, triglyceride, and total cholesterol.
Integrative Medicine Labs to Test for Low Testosterone in Males
To measure hormone level imbalance, a practitioner should order the following.
Testosterone
Serum Testosterone, both total and free to get an idea of what's going on with androgens. Virtually all published studies of testosterone use serum levels as the gold standard. Note: Testosterone is secreted in a daily pattern, and it is therefore recommended to test in the morning to capture peak levels.
Sex Hormone-Binding Globulin (SHBG)
Other hormones that can impact testosterone levels include Sex hormone-binding globulin (SHBG). SHBG is a protein that binds to sex hormones in the body and controls the amount in circulation. If SHBG levels are high, fewer sex hormones are available.
Estradiol
As men’s testosterone levels fall, they may have relatively higher estrogen levels. Serum Estradiol in men can be used to evaluate men with symptoms of estradiol excess, which may manifest as decreased libido or increased body fat.
DUTCH Complete
The DUTCH Complete™ is a urine test evaluating sex hormones, adrenal hormones, and cortisol to provide a useful comprehensive picture of hormones.
Comprehensive Stool Test
A well-functioning gut is essential for overall health and keeps hormone levels balanced. A GI health stool test can evaluate the gut microbiome and any markers for inflammation and digestion/absorption deficiency. A new 2022 study correlated bacteria in the gut microbiome with male testosterone levels (linked and elaborated above).
Complete Thyroid Panel
The thyroid should be evaluated as it impacts mood, energy, and other hormones. A complete thyroid panel is recommended to rule out thyroid disorders.
Other Labs
Because testosterone plays a crucial role in metabolism and vasculature, bone and body composition, other serum lab tests to check include a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Iron panel, iron and ferritin levels, blood glucose, Vitamin D, and kidney and liver health to rule out health concerns and associations.
Iron
Too much iron in the blood can cause testicular failure or pituitary gland dysfunction, affecting testosterone production.
Iron Optimal Range: 85-130
Iron Standard Range: 40-160
Ferritin
Ferritin is a major iron storage protein. It's a marker of total iron stored in the body.
Ferritin Optimal Range for Adult Male 30-190 ng/mL
Glucose
Initial screening for diabetes or early blood sugar dysregulation
Glucose Optimal Range: 75-86
Glucose Standard Range: 65-99
Vitamin D
Vitamin D levels (low and high) are associated with hypogonadism, and Vitamin D Deficiency is directly linked to several health concerns, including osteoporosis, heart disease, cancer, and impaired immune function.
Vitamin D Optimal Range 35-50
Vitamin D Standard Range 30-100
Integrative Medicine Treatment for Low Testosterone in Males
Lifestyle Changes
While testosterone decline is a normal part of a man's life, incorporating strategies to balance lifestyle can mitigate symptoms. Incorporating an anti-inflammatory diet, prioritizing sleep and ideal body weight, avoiding excessive alcohol, practicing consistent physical activity, and using stress management techniques can be helpful.
Supplements
Vitamin D
A small study of vitamin D deficient men who were given 3,332 IU vitamin D daily for one year showed a significant increase in total and free testosterone levels.
Zinc
Adequate zinc intake is associated with optimal production and regulation of testosterone. Food sources including oysters contain more zinc per serving than any other food, but red meat and poultry provide the majority of zinc in the American diet. Other zinc food sources include beans, nuts, and certain types of seafood, such as crab.
Herbs
A 2021 review of herbs and their effects on testosterone showed fenugreek and ashwagandha to have the most significant impact on testosterone concentrations in men.
Hormone Therapy
After a comprehensive assessment, if testosterone replacement is indicated, it is usually prescribed as an injection or via a topical skin gel or patch. Testosterone therapy has demonstrated improvements in symptoms of erectile dysfunction and low libido in men with low testosterone levels. It also impacts metabolism. In a study of 411 men with low testosterone, testosterone therapy produced significant weight loss and decreased waist circumference and body mass index (BMI).
While multiple studies document improvements, patients benefit from an individualized approach. In a study funded by the National Institutes of Health, the amount of testosterone required to maintain lean mass, fat mass, strength, and sexual function varied widely in men.
Testosterone therapy should not be prescribed for any reason with a history of prostate or breast cancer or sensitivity to any of the ingredients in the formulation.
Side effects from prolonged testosterone replacement may include breast enlargement, acne or oily skin, decreased testicular size, and an increased risk of prostate enlargement or prostate cancer.
Summary
Management of low testosterone in males is complex and lends itself to a functional medicine approach because of the overlap of symptoms, causes, and individualized treatment approaches.
A thorough history, physical exam, and specialty laboratory testing will help pinpoint a more accurate and comprehensive assessment to optimize health.
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