Low testosterone, or male hypogonadism as it’s clinically known, is a condition correlated with age, naturally decreasing testosterone levels by 1% each year for men older than age 30. According to the Endocrine Society, roughly 35% of men over 45 years of age suffer from low T, while others have an increased likelihood of developing the condition due to risk factors they may be experiencing.
Your physician will require a venous blood specimen from you, so he can check your testosterone levels. As a guideline, the American Urology Association (AUA) set a threshold of 300 nanograms per deciliter (ng/dL), which marks the minimum amount of normal blood testosterone.
Levels below that threshold fall within the “low testosterone” range, however, prior to making a diagnosis, physicians explore if and what symptoms you may be experiencing. Diagnosing this condition, therefore, doesn’t solely rely on your lab results but also on the symptoms you’re presenting.
But what triggers low T in the first place? How come you never had an issue in the past and are now finding yourself with abnormal testosterone levels? There is a wide array of possible causes — let’s take a look.
The Main Causes of Low T
Before we jump waist-deep into the root causes of low testosterone, it’s imperative we identify the two different types of low testosterone, with each type comprising two additional subgroups.
Here’s an overview of the types of male hypogonadism:
(I) Primary Hypogonadism: caused by a malfunction in the testes
(II) Secondary Hypogonadism: caused by an abnormality in the pituitary gland or hypothalamus
Acquired low testosterone is more frequent than its congenital counterpart. The same rings true for the triggers of secondary hypogonadism versus primary hypogonadism.
(1) The Obesity Epidemic
Obesity has emerged as a growing problem, affecting roughly 42% of the US population according to the Centers for Disease Control and Prevention (CDC). Capable of causing countless health complications, the implications of obesity — encompassing a sedentary lifestyle and the lack of exercise, are of serious concern.
A study on total and free testosterone found that moderate obesity mainly reduced total testosterone levels due to insulin resistance as it lowered the sex hormone binding globulin. More severe obesity was found to primarily lower free testosterone levels.
Hypogonadism caused by obesity is considered reversible but presumes that the individual can commit to significant weight loss.
(2) Uncontrolled Diabetes
Going hand-in-hand with climbing rates of obesity is the prevalence of type II diabetes mellitus. According to the CDC, today about 37 million Americans suffer from diabetes, which equates to roughly 11.3% of the US population.
But with risk factors for diabetes also on the rise, 38% of Americans now live with prediabetes — meaning that a large percentage of those not suffering from diabetes yet are sadly on the path to developing the disease.
Poorly controlled diabetes exacerbates the situation further, increasing your risk of developing additional conditions. The American Diabetes Association notes that men with diabetes are twice as likely to develop low testosterone — a significant difference when compared to healthy individuals.
A meta-analysis found a connection between low testosterone levels and type II diabetes, as low testosterone levels are linked to insulin resistance.
(3) Medication Side Effects
One of the main causes of low T is not an underlying medical problem but a side effect of certain medications. Whether it’s over-the-counter or prescription drugs, certain meds can have short-term and sometimes long-term effects on the production of testosterone. Some of these medications include estrogen drugs and some androgen biosynthesis inhibitors.
Metoclopramide, commonly used to treat gastroesophageal reflux (GERD), has also been found to contribute to low testosterone. A study revealed that 10 mg of Metoclopramide QID (4 times daily) decreased testosterone levels in patients, while simultaneously affecting prolactin levels.
Other medications that have been found to impact the male sex hormone range from opioids (particularly long-acting opioids) to injections used for prostate cancer (like goserelin and triptorelin), as well as radiation in the larger context of cancer treatments.
(4) The Oxymoron Surrounding Anabolic Steroids
Anabolic steroids are generally prescribed to treat primary male hypogonadism in patients with confirmed low testosterone levels. So how can they contribute to low T at the same time?
The issue with anabolic steroids is that unprescribed use is common, leading to an array of side effects and medical complications after cessation. One study found that former anabolic steroid abusers demonstrated significantly lower testosterone levels than healthy control participants years after anabolic steroid cessation. Known to help build lean muscles and increase your body mass index (BMI), sometimes these drugs are misused to enhance physical appearance and performance.
Technically, anabolic steroids are class C drugs and can only be obtained with a prescription and from a qualified pharmacist. However, illegal consumption is not unlikely. The National Institute on Drug Abuse (NIH) lists serious health risks as a consequence of its long-term use, including early heart attacks, strokes, and kidney failure.
(5) Alcohol Abuse & Liver Cirrhosis
Another primary cause of low T is the excessive consumption of alcohol as it can affect multiple facets of the male reproductive system. Alcohol can negatively impact the Leydig cells in the testes, which are responsible for the production of testosterone — with research confirming a decrease in blood testosterone levels correlating with heavy alcohol intake.
But that’s not all. The implications of alcohol consumption can reach as far as your brain, influencing the hormone production in both your hypothalamus and your pituitary gland.
Liver cirrhosis, which can originate from long-term alcohol abuse, has also been linked to low testosterone levels. One study found that the serum testosterone in men with liver cirrhosis was a whopping 90% reduced — all while levels further plummeted with cirrhosis progression.
Understanding the Main Causes of Low T
If you have been diagnosed with low testosterone, identifying the root cause of your hypogonadism with your physician can help you understand your condition better. Together you will determine the next steps and whether or not you are a candidate for testosterone replacement therapy.
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