Does the diminution that age brings with it in both total and bioavailable T have any clinical significance? This question leads us to the theme of this paper, “The Many Faces of Testosterone”. If testosterone were simply a “sex hormone” involved only with sexual desire and arousal we might tend to dismiss testosterone treatment in the aging man as merely a “life-style” therapy without any substantive basis for broad physiological necessity. The fact is, however, that the sexual attributes of testosterone are the least of its physiological necessities and that testosterone has a broad spectrum of demonstrated physiological functions as well as a wide variety of physiological and pathophysiological associations about which we are just learning.
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Testosterone is a hormone with multifaceted physiological functions and multiple associations with pathophysiological states. It is an important hormone in male reproductive and metabolic function from intrauterine life to old age. In severe or classical hypogonadal states there is little controversy about the need to administer testosterone by an intramuscular, oral or transdermal formulation. There is controversy about making the diagnosis in the less severe cases of hypogonadism associated with the aging male but the current evidence suggests that this is efficacious in appropriately selected men and that there is little if any risk in giving aging symptomatic hypogonadal men a 6 month trial of therapy to determine whether symptoms will improve.
Recently, a panel with cooperation from international andrology and urology societies, published specific recommendations with regard to the diagnosis of Late-onset Hypogonadism (Nieschlag et al 2005). These are summarized in the following text. It is advised that at least two serum testosterone measurements, taken before 11 am on different mornings, are necessary to confirm the diagnosis. The second sample should also include measurement of gonadotrophin and prolactin levels, which may indicate the need for further investigations for pituitary disease. Patients with serum total testosterone consistently below 8 nmol/l invariably demonstrate the clinical syndrome of hypogonadism and are likely to benefit from treatment. Patients with serum total testosterone in the range 8–12 nmol/l often have symptoms attributable to hypogonadism and it may be decided to offer either a clinical trial of testosterone treatment or to make further efforts to define serum bioavailable or free testosterone and then reconsider treatment. Patients with serum total testosterone persistently above 12 nmol/l do not have hypogonadism and symptoms are likely to be due to other disease states or ageing per se so testosterone treatment is not indicated.
Although some men believe that taking testosterone medications may help them feel younger and more vigorous as they age, few rigorous studies have examined testosterone therapy in men who have healthy testosterone levels. And some small studies have revealed mixed results. For example, in one study healthy men who took testosterone medications increased muscle mass but didn't gain strength.
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