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Testosterone Deficiency is both under-recognised and under-diagnosed

There is a fundamental lack of understanding and awareness surrounding the importance of testosterone in both physical and psychological health. Healthy hormone levels are necessary for life, there is no biological advantage in accepting low levels.

What is Testosterone Deficiency?

Testosterone Deficiency Defined:

Testosterone Deficiency is a recognised medical condition and there are current UK specific guidelines for it’s treatment.  Low testosterone can have a significant impact on both short-term and long-term physical and psychological health.  It is an under-recognised and under-diagnosed condition.  The Men’s Health Clinic is working hard to increase both awareness and understanding so that more men can have safe and effective access to the care that they need.

The British Society for Sexual Medicine (BSSM) defines Testosterone Deficiency as:

“A well-established and significant medical condition.  It is defined as a clinical and biochemical syndrome associated with advancing age and comorbidities and is characterized by a deficiency in serum androgen levels (with or without decreased genomic sensitivity to androgens) and relevant signs and symptoms.”

“Testosterone Deficiency can adversely affect multiple organ systems and result in significant decreases in quality of life, including changes in sexual function.”

Terms like the ‘Male Menopause’ and the ‘Andropause’ serve no other purpose than to mislead the general public and trivialise something that can have a significant impact on someone’s quality and quantity of life.  You wouldn’t deny a diabetic insulin, or show disdain for a hypothyroid patient requesting the most effective medications available, so why not apply the same standard to Testosterone Deficiency


It is important to appreciate that there can be many other causes for low testosterone symptoms and so it is vital to first explore other possible diagnoses through a thorough medical history, physical examination and appropriate blood investigations.

Common presenting symptoms of low testosterone include:


Low Mood – Anxiety – Depersonalisation

Normalisation of male androgen levels typically leads to an improvement in mental well-being.  A growing number of our patients no longer need anti-depressants as a result of therapy.



This can be quite debilitating, especially as concerns are often attributed to ‘aging’ and aren’t always taken seriously.  TRT usually improves energy levels, drive and determination, allowing you to take that next step forwards.


“Brain Fog”

There is often a decline in cognitive function, whether that be muddled thinking or loss of short term memory.  That fogginess can clear with TRT, making you feel like you again.


Low Libido

Low sex-drive is common.  Men often complain of losing that “spark”.  Testosterone is key to sexual desire and drive.


Erectile Dysfunction

This can be quite embarrassing.  The loss of morning erections is a good sign that something is wrong.


Loss of Strength and Lean Muscle Mass

Not a common presenting symptom but noteworthy.  Not keeping up with your old self is a tell-tail indicator.  Normalisation heralds a return of your previous stature.


Increased Body Fat

A common complaint is not being able to lose weight despite a healthy diet and training regime.  A positive change in body composition is noted over time with TRT.



An alarming and significant presenting symptom.  It’s not as rare as one might think.  Testosterone is integral for bone strength.


When exploring the possibility of Testosterone Deficiency, we recommend a comprehensive diagnostic blood test, which can be arranged through clinic if required. This tests need to be drawn between 07:00-11:00, in a fasted state, and not during an episode of acute illness.  You would then need a second, more basic, confirmatory test four weeks later to confirm the diagnosis.

A comprehensive diagnostic blood test should include the following:

  • Total Testosterone
  • Free Testosterone
  • Follicle Stimulating Hormone
  • Lutenising Hormone
  • Sex Hormone Binding Globulin
  • Prolactin
  • Oestradiol
  • Full Blood Count
  • Prostate Specific Antigen
  • Urea & Electrolytes
  • Liver Function Tests
  • HbA1C
  • Lipids incl. Cholesterol
  • Thyroid Function Tests

This thorough compliment of blood tests is necessary for an accurate diagnosis, and identifies some potentially reversible causes and contraindications to therapy.  We support our clinical assessment with the use of validated pre-screening questionnaires such as the Aging Male Symptoms Scale, to provide a quantitative baseline assessment of baseline symptoms.

Testosterone Replacement Therapy should only be prescribed if clinically indicated and is in your best interests.  It should be considered a lifelong therapy and a considered decision between you and your clinician, after weighing up the pros and cons of therapy.

British Society for Sexual Medicine vs The NHS:

The British Society for Sexual Medicine (BSSM) have produced national UK guidance, based on the latest available evidence, to support all doctors in providing safe and effective care to patients with confirmed Testosterone Deficiency.  These are excerpts from the current guidelines:

“Serum T should be measured from 7 to 11 AM on at least 2 occasions with a reliable method preferably 4 weeks apart and, if possible, not during an acute illness.”

“Regarding the thresholds for treatment intervention in symptomatic men, BSSM and ISSM guidelines recommend the following:

TT level lower than 8 nmol/L or FT level lower than 180pmol/L (<0.180 nmol/L; based on 2 separate levels from 8 to 11 AM) usually requires T therapy.

Levels from 8 to 12 nmol/L might require a trial of T therapy for a minimum of 6 months based on symptoms.

A FT level lower than 225 pmol/L (0.225 nmol/L) provides supportive evidence for T therapy in the presence of appropriate symptoms.”

Despite this guidance, Testosterone Deficiency is still a medical condition very misunderstood by most doctors in the UK and can be extremely difficult to get treatment for under the NHS.  Rather than treat their patient using the guidelines available to them, GP’s will often refer patients to their local Endocrinology department.  Unfortunately, the large majority of endocrinologists in the UK will not adhere to the BSSM guidelines in favour of their own guidelines which restrict them to only treating ‘abnormal’ hormone levels.  NHS Endocrinologists are bound by the reference range their laboratory uses, so if you fall within that reference range and they cannot identify a pathology, you will struggle to be prescribed TRT.

Clinical guidelines are there to ensure that doctors are acting in the best interests of their patient.  NHS Endocrinologists also want to act in your best interests, however when considering your hormone blood test results and regional variation in reference ranges, there will be the resulting variance in what are considered to be ‘normal’ testosterone levels by endocrinologists all over the UK.  Reference ranges are constantly lowering which, in our opinion, reflects our sick society.  We may be living longer, but our quality of life is no better despite advances in modern medicine.

The Society for Endocrinology’s latest position statement on “male hypogonadism and ageing” suggests that “Hypogonadism is misdiagnosedover-diagnosed and undiagnosed in equal measures.”  We cannot over-emphasise the importance of a thorough diagnostic work-up by a clinician who specialises in the field, who understands the importance of working with your best interests at the core of everything that they do.

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