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Will a Doctor Prescribe Testosterone When Your Level is “Normal”

If you ask a doctor to prescribe Testosterone and your total testosterone level is in the mid range, they will probably not treat you.

The key to testosterone replacement is whether or not you are symptomatic. A rapid and easy way to screen for symptoms is the Androgen Deficiency in the Aging Male (ADAM) score. A yes answer to question 1, question 7 or a score of three or higher out of ten questions indicates that your testosterone level may not be optimal for you. Here is the questionnaire:

The sensitivity of the ADAM score is around 90% but the specificity is only 30% meaning it will correctly identify low testosterone levels in men 30% of the time.

The issue with those statistics? The testosterone level reference range is merely a Gaussian distribution, or Bell Curve, for that particular lab. Most labs consider the lower limit of normal testosterone level to be about 250–300 for 95% of adult males. Total testosterone levels lower than that are considered “abnormal”.

What if your testosterone level is 301? That result is statistically normal.

If a man is in the low normal range and is symptomatic, then his testosterone level is suboptimal for him and he may benefit from even low dose testosterone replacement. Men lose 1–3% of their testosterone production yearly starting at age 30.

To try and address the lack of specificity, a group developed the Quantitative ADAM score. Answering these questions gives a score of 10 (most symptomatic)-50 (least symptomatic. In the study, low testosterone levels were considered less than 300.

To try and address the lack of specificity, a group developed the Quantitative ADAM score. Answering these questions gives a score of 10 (most symptomatic)-50 (least symptomatic. In the study, low testosterone levels were considered less than 300.

A score of 30 or lower correlated with hypogonadal testosterone levels. The specificity in this study was 32%, similar to the original ADAM Questionnaire from St. Louis University. Here are the results of their study:

Note that some men with borderline low testosterone levels had few symptoms. These would be guys that do not meet the indication for testosterone replacement therapy.

Scoring on both tests provide the indication to measure serum testosterone levels. Answering yes to lower sex drive or less firm erections also is an indication for testosterone evaluation.

So here is the problem. Total testosterone levels really don’t tell the whole story. Total testosterone blood tests measure bound and unbound testosterone and can be very variable. Sex Hormone Binding Globulin (SHBG) binds most serum testosterone so it is not bioavailable and does not interact with testosterone receptors. SHBG has been called the “joker in the deck” (by Dr. Abraham Morgentaler at Harvard Medical School) as its levels vary significantly within the same man (or woman). Older age and various medications elevate SHBG levels.

Free (unbound) testosterone is bioavailable. There is weak binding of some testosterone to the protein albumin. That testosterone is also bioavailable. So there are really three kinds of testosterone running around in there. You need to know what’s available to do the work of testosterone because bound testosterone is not.

You have to measure SHBG for a lab to calculate free testosterone levels. Direct measures of free testosterone are so variable they are unreliable. This is the important test (among others) that leads to identifying symptomatic men that may benefit from testosterone replacement with close monitoring.

I have evaluated many men for low testosterone symptoms whose other physicians had told them their testosterone levels were in the normal range. That was true of their total testosterone levels but measuring free testosterone uncovered many symptomatic guys in the lower 5th percentile for levels of that bioavailable hormone.

A typical example would be a 50-ish aged guy with an ADAM score of 7 (81–96% sensitivity) who has a total testosterone of 550 (Clinical Pathology Laboratory’s reference range of 250–1180 ng/dL for all adult males). His result is midrange and the lab reports a normal testosterone level. The doctor says no indication for testosterone and sends him on his way with no other evaluation.

Presenting to me, he still has an ADAM score of 7. We check his free/total testosterone, estradiol, Complete Blood Count and Prostate Specific Antigen for screening, calling him the next day with results.

His estradiol, CBC and PSA levels are all normal. His total testosterone level comes back 570. But his free testosterone level is 3.4 with a normal reference range of 4.5–25 ng/dL at Clinical Pathology Laboratory.

An otherwise healthy guy like this has significantly low testosterone available to him leading to his symptoms. The specificity scoring of the two questionnaires above were based on total testosterone levels. So the ADAM score didn’t pick him up from his total testosterone level. It picked him up from his free testosterone level.

A symptomatic man such as this with no other health issues deserves to hear his options for improving his free testosterone level to reduce his ADAM score. He needs to hear the risks and benefits of testosterone replacement as well as other options to make his own informed decision.

The goal of choosing a treatment option is to improve free testosterone toward the upper range of normal without going over the top. Low testosterone symptoms disappear rapidly and men that are working out develop better muscle mass and tone. Monitoring every 10–12 weeks for men choosing testosterone replacement keeps them healthy and out of trouble.

That is the Art of Medicine.

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