“I just feel Bleh”.
This is often preceded by a list of symptoms such as fatigue, weight gain around the middle, difficulty concentrating at work, diminished sex drive, and body aches. Or, sometimes, the person in front of me wraps it all in a tight little bundle and says that he “just feels bleh”.
When I hear these words, my ears perk up as if he’s pulled the magic handle on the slot machine because this is a language I understand.
“Low testosterone” (aka “Low T”) is more appropriately called hypogonadism. Some people might say that over-treatment of low testosterone has become an epidemic. There is some validity in this, but I’d also argue that the treatment is less of an epidemic than the disease itself.
A study in 2007 revealed a “substantial” drop in men’s testosterone levels across the U.S compared to just 25 years previous. In fact, at that time it was noted that beginning in the 1980’s each subsequent year has meant an approximately 1% decline in the population’s testosterone levels. To put this in perspective, a 40 year-old man in 1980 likely had a total testosterone level 40% higher than a 40 year-old man in 2020. Another Danish study showed that this trending decline in testosterone didn’t start in the 1980’s, but has been going on for almost 100 years.
This is worrisome. So, what have we done about it? Well, if you’re a laboratory that runs testosterone tests all day long, the answer is to simply change the reference range to what is now the new normal.
In 2017 LabCorp, one of the biggest labs in the United States, changed their reference range for total testosterone. Other labs have done the same. Previously, an adult male aged 18-40 was considered normal if he had a total testosterone between 348 ng/dL and 1197 ng/dL. Now, he’s considered normal if his testosterone is between 264 ng/dL and 916 ng/dL. The reference range goes down even further for men in older age brackets. LabCorp noted that the new reference range “reflects a difference in average subjects with higher BMI’s…”
We know that obesity is one of the major causes of low testosterone. Other causes likely include the fact that we sit around more, don’t lift as much heavy stuff, eat more sugar, don’t get as much sunshine, and surround ourselves with environmental hormone disruptors (among other things).
Okay, so we’ve adapted to a new world and our men have lower testosterone. Why does that matter? It matters. Low testosterone increases all-cause mortality rate in men. It is a major risk factor for premature cardiovascular death. It is a risk factor for metabolic syndrome and type 2 diabetes, as well as hypertension and dyslipidemia. Low testosterone is also associated with an increased risk of mental disorders, such as depression and anxiety, as well as cognitive impairment and sexual dysfunction. Declining levels of testosterone are paralleling men’s declining sperm counts and the associated increase in infertility that we’ve seen in the last few decades.
Clearly, the answer is not to simply give men syringes full of testosterone during a once-yearly clinic visit. Obviously we need to first work to correct all of the precipitating events and conditions that have led to the low testosterone. Lifestyle changes are always the first place to start when dealing with a man with this problem. But, sometimes a little help is, well, helpful.
For example, if I have an obese, diabetic 50-year old man with low testosterone come to me feeling miserable, I’ll definitely begin by trying to help him make better daily choices. But, low testosterone can cause fatigue, lack of motivation, and difficulty gaining muscle. So, he’s going to have a much harder time losing weight and getting his blood sugar under control than someone without low testosterone. For him, starting testosterone therapy may be just the kick in the butt his body and mind need to begin the long trek back to health.
“Feeling bleh” may not sound like a big deal to you, but to me, it is the cry for help of a generation of men who knows something isn’t right, but doesn’t have the words to express the totality of the problem. Instead of adjusting our expectations, tweaking our lab reference ranges, and putting testosterone-therapy-shaped band-aids on our men, maybe it’s time to own up to the fact that “Low T” is a health epidemic that is making men more frail, less motivated, more depressed, more chronically ill, less able to father children, and more likely to die at a younger age. Instead of normalizing it, maybe it’s time to do something about it.