r. Larry Goldenberg is the founder of the Canadian Men’s Health Foundation. In 2015, he was a co-author of the Canadian guidelines on the diagnosis and management of testosterone deficiency syndrome.

These guidelines are providing a much-needed framework for both the diagnosis and treatment of testosterone deficiency. Without such a framework, Canadian doctors have been to a certain degree lost in the weeds. The problem is that while there is a simple blood test for testosterone levels, the results of that test are not diagnostic on their own.

“I could have a testosterone level today of eight, which lab evaluations would say is low. But, if 20 years ago my testosterone was nine, then that’s not low — that’s just my level,” explains Dr. Goldenberg. “At the same time, if a guy comes in with a testosterone level in the normal range — around 13 or 14 — but 20 years ago it was 20, then for him that might be an issue. Our challenge on a day-to-day basis is that we don’t know what normal is for a given individual.”

These natural variations in testosterone levels among men present obvious problems in diagnosing late-onset hypogonadism based on test results alone, especially when baseline testosterone readings from earlier in a man’s life are unavailable, as is too often the case. There has been a lot of concern in the past that this has led to overdiagnosis and overtreatment in healthy men. The new guidelines are very clear that proper diagnosis should integrate both clinical symptoms and laboratory results.

Good treatment options exist

When a well-supported diagnosis has in fact been made, the prognosis with testosterone supplementation can be very good. “If you see men with very low testosterone who are really feeling the impacts of it, and you bring them back up to normal levels, you’re really going to see remarkable improvements,” says Dr. Goldenberg. “They feel better; they sleep better; their mood is better; they’re better able to concentrate; they feel stronger; they lose weight. And, from a sexual point of view, their libido is improved, and their erections are often improved as well.”

“Eat well, diet properly,
exercise, and your
testosterone level
will naturally come up.”

When testosterone supplementation is indicated, Canadians have a wide variety of choices available to them. There are injections, there are oral tablets, there are transdermal patches, there are topical solutions and gels, and most recently, there is a new product that is applied in the nose. The guidelines are clear that determining the right formulation and delivery system is a topic that should be addressed in a conversation between a patient and his doctor, but each has pros and cons in relation to a number of factors, including safety, efficacy, convenience, and cost.

“The injections are the cheapest way to go, but there are issues because you get peaks and valleys. The day after an injection you get a very high level of testosterone, but then it drops off, so that just before your next injection, it can be quite low,” says Dr. Goldenberg. “The gels are probably the best way to give you a steady level of testosterone, but they can be pricey.” The topical gels and solutions can also be cumbersome to apply, which often leads to compliance issues. Patients must be careful not to transfer the testosterone to women or children.

Multiple paths to positive outcomes

Dr. Goldenberg also stresses that supplementation is not the only way to treat testosterone deficiency, especially among less dramatic cases. “Probably the best way to treat a minor testosterone deficiency is simply to lose weight,” he says. “Eat well, diet properly, exercise, and your testosterone level will naturally come up.”

In all, the treatment options provide a very positive outlook for men with testosterone deficiency syndrome, and most importantly, the new guidelines provide a roadmap toward responsible diagnosis and treatment. Hopefully these guidelines will play a major role in cutting through the fog of uncertainty and controversy that has plagued treatment of this condition in the past.