HRT for middle-aged men: 'I went on testosterone therapy to keep my marriage strong'

Male menopause is often overlooked with many Irish men suffering in silence. But for those with low testosterone levels, hormone replacement therapy can help to improve their sex drive, health and relationships

Pic: iStock

Dr John Sullivan meets a lot of men who don’t want to open up about their sexual health.

“Irish men don’t go down the pub and talk about how their sex drive or their erection quality has decreased,” says Sullivan, consultant urologist in St James’s Hospital, Dublin.

Yet what he observed when he worked for a while in Texas was very different — American men were a lot more at ease with their sexual health. 

“They understood that maintaining normal levels of testosterone was going to improve their sex drive, health, and relationships. We saw them come in their droves [for support].”

It is unfortunate, Sullivan says, that in Ireland the male menopause has been grossly under-acknowledged. “A lot of men suffer in silence. And really there’s no doubt the hormonal perturbation that a man goes through in his 50s, 60s, and 70s can be addressed, and men can be supported to feel a lot better.”

A normal total testosterone level is between 12 and 35nmol per litre, but from age 40 a man’s testosterone level declines approximately 1% every year. “Incidence of low testosterone in middle-aged men from European data is approximately 10%,” Sullivan says.

Dr Emmett Byrne, GP and men’s health specialist at Preventive Health Clinic in Bray, says testosterone deficiency is the second most common endocrine disorder in men after type 2 diabetes. 

He cites three lead symptoms: Low libido, loss of early morning erections — “this is nothing to do with arousal, but with oxygenation of the tissues of the penis” — and erectile dysfunction. 

“The symptom I hear most is low libido, the second most common is fatigue, and the third is anxiety.”

But there are additional symptoms, says Byrne: “Increased bodyweight around the tummy, loss of strength and muscle mass, and psychological symptoms like low mood and confidence. Men also get higher risk of certain cardio-metabolic diseases — risk for diabetes and osteoporosis goes up.”

Sullivan adds further signs: Decreased endurance and concentration levels. “It’s quite impressive — the extent of symptoms a man can present with,” he says, adding that it is essential other causes are ruled out before starting treatment for low testosterone. 

“It could be there’s some other uncovered endocrine disorder. Very possibly issues with depression and low mood which mightn’t be linked at all to low testosterone.”

Dr John Sullivan, urologist at St James' Hospital

Challenges of ageing

Psychologist and honorary secretary of the Psychological Society of Ireland Dr Damien Lowry agrees that mental health symptoms in middle-age may not be caused by testosterone deficiency. He cautions against pathologising the ageing process. “The life span is longer than it has ever been, which is a blessing, but also a challenge. By virtue of living longer, we’re having to deal with the challenges of ageing.

“And sometimes what we might assume to be testosterone deficiency might be an underlying mental health issue. It might be work-related stress, or not having enough time to relax, unplug and fulfil other valued areas of one’s life. This can impact mood, mindset and libido.”

Where physiology ends and psychology begins, he says, isn’t always clear-cut. “It’s far more overlapping than we might assume. I’m in no way discounting there is sometimes a clear drop-off in testosterone levels, but that this is medically evaluated is very important.”

A simple blood test — which can be taken by the GP — alongside the display of symptoms will lead to a diagnosis. But it is not as straightforward as it sounds. For one thing testosterone levels can fluctuate — one isolated low level from a blood test doesn’t make a diagnosis. 

“The test needs to be repeated on two separate occasions and ideally performed before 11am. There’s a circadian rhythm for testosterone levels and a man’s peak level will be between 3 and 8am,” says Sullivan.

Studies show when blood is drawn from 30- to 40-year-old men at 4pm, their testosterone levels will be 25% lower than if done in the morning. “When men get into their 50s, 60s, 70s, they’ve less of a decrease through the day. Younger men have higher peaks and troughs.”

So what constitutes testosterone deficiency? “Strictly speaking, it’s [a level] less than eight,” says Sullivan. “But if men are displaying significant symptoms and have anything less than 12, we would treat.”

Whether GP, endocrinologist or urologist, doctors treat similarly in accordance with published guidelines, Sullivan explains. Yet, when men have a natural decline in testosterone, they don’t just get a testosterone prescription straightaway. 

“We suggest improving diet and lifestyle, optimising exercise — especially resistance exercise — improving sleep quality, controlling stress and managing issues like diabetes or obesity,” says Sullivan, adding that these measures often increase/restore testosterone to normal levels.

“But if after a six-month period of a man doing everything to improve his lifestyle, he still has low testosterone blood levels — and symptoms — it’s time to offer testosterone therapy.”

Dr Emmett Byrne, GP and men's health specialist

Testosterone therapy

Does Viagra have any role? It is a mistake to think the erectile dysfunction (ED) drug could be used as any kind of stop-gap measure for low testosterone. 

Sullivan explains: “Viagra is medication that directly treats ED — it increases blood flow to the penis, thereby increasing quality of the erection. So it should enhance the erection but it has no effect on testosterone levels — it won’t do anything for [loss of] sex drive or any other symptoms of low testosterone.”

Currently in Ireland, testosterone is given as a topical gel or as a short-(seven to 10 days) or long-acting (12 weeks) intramuscular injection. In the US, men can also avail of oral, nasal spray and subcutaneous pellet options. Testosterone therapy, says Sullivan, is generally for a man’s lifetime.

He emphasises how important it is that treatment is in a controlled setting, delivered and monitored by a doctor. “It’s extremely important that a man, displaying symptoms of low testosterone, gets thoroughly assessed by a doctor because there could be many reasons for his symptoms.”

He believes “there’s a lot of underground prescribing of testosterone, which is highly unsafe”, with men drawn to the internet and pop-up clinics, where those prescribing are not testing the man’s testosterone level at the outset. “A US study showed up to 25% of men receiving testosterone didn’t have their levels checked before treatment initiated.”

Sullivan says the problem is also occurring here. “There’s certainly a cohort of men in Ireland, ordering testosterone therapy online from the UK and other parts of Europe, who are never seen by a doctor.” 

Pointing to increased attention to body image and physical appearance across all Irish society, he says: “I wouldn’t want to over-alarm, but certainly there’s a small percentage of individuals taking testosterone who aren’t deficient in it but just want to bulk up to look better.”

But what many men don’t realise, he says, is when they’re taking testosterone therapy they’re rendered temporarily infertile. 

“When you use exogenous treatment — supplying it to the body — you shut down the body’s own production of testosterone. Sperm production stops. Many men don’t know this. It can be reversed if you stop taking testosterone, but it takes about a year on average to recover sperm parameters — and about 5% never recover sperm at all.”

One problem with not being regularly monitored by a doctor during treatment — not getting regular physical examinations and blood tests — is that side effects won’t be picked up on. 

Sullivan cites some of these: “Patients can develop high red blood cell count levels, which needs monitoring. Rarely, they can develop breast tenderness and acne. There’s increased risk of sleep apnoea. It’s low risk for these — in the single percentages — but patient awareness is important.”

Men who go underground to source testosterone may also be unaware of the potential for transference if using rub-on testosterone gels. “Children and partners can be exposed to the testosterone and, as a result, side-effects can be transferred to them.”

Debunking myths

While traditionally testosterone therapy was considered very high-risk, Sullivan says in fact it is a very safe treatment in the monitored setting. But there are contraindications — and men who should not take it, such as those who have a baseline high red blood cell count level or who have severe obstructive sleep apnoea. Men with significant cardiac disease or congestive cardiac failure, or who have a history of male breast cancer, are also ruled out.

“And if men desire to have children they shouldn’t have testosterone until their family is complete,” says Sullivan, though he points to a way around this — freezing sperm to use in subsequent IVF treatment.

He also wants to debunk some testosterone myths. Citing the recent landmark Traverse Study, published in New England Journal of Medicine in July, he says there’s no evidence to show testosterone is a risk factor for cardiovascular disease or for major cardiac events. “There’s also no definitive evidence linking it to higher incidence of blood clots.”

The other myth he wants to dispel relates to prostate cancer. “About 15% of men in Ireland will receive a diagnosis of prostate cancer. But as men get older, they often have low testosterone. So it’s common for low testosterone and prostate cancer to co-exist together.

“The traditional view was that giving testosterone therapy was ‘fuel for prostate cancer’ and was like ‘pouring gasoline on the fire’. But there’s an absence of evidence linking testosterone therapy to development of prostate cancer.”

Sullivan says men undoubtedly are being diagnosed with testosterone deficiency at an earlier age than previously. So did covid have any effect on testosterone levels? Sullivan is clear. “Like any other severe infection, covid puts the body under mental and physical stress, so testosterone levels will be blunted. But it’s important to uncouple any direct link between covid and low testosterone.”

Earlier age diagnosis, he says, is due to increased awareness of testosterone deficiency. “There’s more in the media and on the internet. GPs are more clued into the symptoms and signs — they’re asking questions more.”

And this is a good thing, he says, because it means testosterone deficiency — and how men suffer as a result — is coming in from the cold. “It’s important that we bring testosterone therapy into a very acceptable and safe space.”

'I wanted to keep my strong marriage'

Dublin-based Ronan, 52, married for 25 years, has four children ranging from mid-20s down to 12. He has been on testosterone therapy for three years.

“The obvious thing people always assume about low testosterone is that it has to do with sexual function — and I’d noticed a decline. It wasn’t completely gone but I was certainly conscious it wasn’t what it had been.

“I was also very tired in the evenings after work. There was no reason for it — I don’t do physical work. I work in IT. Also, those around me thought I’d got a little bit ratty.

“I went on the internet and landed on testosterone deficiency. There wasn’t really that much information other than from US websites.”

Ronan went to a GP but says his experience was “terribly disappointing”. A first blood test didn’t check his testosterone levels though he had asked for this. “They sent another sample to the lab and the level came back at the lower end of normal for my age. The doctor said I was tired and stressed and put me on an anti-depressant.”

On an online forum, Ronan came across pioneering medic and founder of Clane General Hospital Dr Andrew Rynne. After taking what Ronan describes as a “symptomatic holistic” view, Dr Rynne prescribed a slow-release testosterone injection and advised Ronan to come off the anti-depressant immediately. 

“My symptoms all improved within 10 days — my energy levels were through the roof, my sexual function was greatly restored and nobody ever said anything about the crankiness again. I felt a whole lot better.”

Since Dr Rynne retired, Ronan has been under Dr Emmett Byrne’s care. “He’s very vigilant and does a blood test every second visit.”

At one stage during the pandemic, Ronan couldn’t attend at his usual 10-week interval for therapy. “It went to 15 weeks and I could feel the difference — I could certainly feel it wearing off.”

He wishes for more awareness among men about testosterone decline in middle age. “Men are never told that by age 50 their hormone level could cause them difficulties. Men don’t talk as readily as women do. There’s machoism in it too. Some men give up. They think ‘My sexual function isn’t right, I won’t face that’ — they go to the pub with the lads, sweep it under the carpet.

“I didn’t want that. I have a very strong marriage and relationship and I wanted to keep that.”