“I am tired all the time and my primary care doctor found my testosterone is low”
I deal with some variation of this chief complaint several times per week. As urologists, we deal with the many endocrine abnormalities involving the testosterone axis. The more I’ve encountered and studied this clinical theme in my career, the more compelled I feel to dispel the assumption of causality between fatigue and low testosterone.
First and foremost, in my clinical judgement, testosterone levels need to consistently remain in the 200 ng/ml range for there to be any meaningful clinical impact. Secondly, the main value of testosterone replacement is in improving sex drive, bone mineral density, anemia and improving lean body mass. If this isn’t a critical part of a chief complaint, testosterone deficiency is unlikely.
When I explore the issue of fatigue in these men, invariably there are other far more important factors that I feel are causing their symptoms. Chief among these are sleeping patterns. The majority of these men sleep poorly. We spend 1/3 of our life sleeping and yet, I am always amazed by how few primary care doctors explore sleep hygiene. Sleep deprivation has a far greater impact on tiredness and fatigue than any other variable I know. These men consistently have interrupted sleep, signs of sleep apnea with snoring and daytime somnolence, or work the 3rd shift and sleep during daytime hours. Few of these men report their primary care doctors exploring these issues.
Other factors that are also seen in these men include poor diets made up of fast food and junk, and little or no exercise. Exploring these issues with patients can be enlightening, as other than a casual encouragement, few clinicians delve into the specifics of a day to day diet. Encouraging increased good fat consumption, more focus on a plant based diet, and decreasing sugar consumption are concepts I explore with all of these patients.
Earlier in my career, and even now occasionally, I have used a 3 month trial of administering testosterone to see if the intense fatigue reported in these men improves. However, I have rarely, if ever, seen it improve their fatigue despite improving testosterone to normal and above normal levels.
The issue of testosterone replacement itself is quite controversial. The FDA has warned that testosterone administration is ripe for abuse due to perceived benefits for possible athletic performance enhancement. Further, there is increasing and compelling evidence that testosterone replacement is linked to higher risk of stroke and heart disease.
I personally have found the push for testosterone in the setting of nonspecific fatigue complaints emblematic of a larger problem in society and medicine – that of seeking quick solution to problems in the form of a pill or medicine when the problems are often more complex and nuanced, requiring difficult lifestyle changes. Patients are eager to get a quick answer in the form of medicine and doctors are too willing to oblige (think the rampant use of antibiotics for viral infections or other unclear clinical pictures). This explains why sleep, diet and exercise are rarely discussed. Financial incentives promote this culture as “doing something” medically tends to code and reimburse higher than lifestyle counseling.
As I have explored in a previous blog, correlation and causation as a concept is something most clinicians don’t try to understand or explore. Two factors can be true without being related. And finally, many of these men are quite young, in their early 40s or 50s when seen. Once starting on testosterone, endogenous testosterone production plummets, and they become completely reliant on exogenous source. As a result, testosterone replacement becomes a self-fulling endeavor, one that has long term detrimental effects.