Low Testosterone Opens the Door to a Broader Health Conversation

Low testosterone has been at the center of many cultural, medical and even military conversations in the U.S.

Mark Paulos, MD, a Cleveland Clinic internal medicine physician specializing in andrology and sexual medicine, says this increased awareness is beneficial to the extent that it empowers men to take action on their health. However, he stresses that low testosterone should be interpreted as an indicator of overall health, not as an isolated issue.

“Testosterone decline is strongly influenced by obesity, metabolic health, and sleep duration and quality,” he says. Unlike menopause in women, he explains, testosterone decline in men is not a biological inevitability.

Greater awareness, but also greater risk

Direct-to-consumer platforms offering exogenous testosterone can oversimplify the issue, exaggerating the benefits of testosterone and prescribing without performing a thorough history or appropriate lab testing. Still, Dr. Paulos says a potential benefit is that conversations about men’s health have been normalized and brought into the mainstream.

Dr. Paulos’ practice focuses on men who have confirmed or suspected testosterone deficiency and are seeking specialty evaluation and treatment options. Many report low libido, fatigue, sexual dysfunction, loss of muscle mass and visceral weight gain.

While symptoms alone are not diagnostic, they can be an important starting point for a more comprehensive evaluation. “Some men have symptoms but normal testosterone, which can lead to a diagnosis of important conditions that present with similar symptoms like depression or sleep disorders,” he says.

When preserving fertility is a priority

He also treats younger men with low testosterone who are interested in preserving fertility. For these men, exogenous testosterone is contraindicated as it suppresses sperm production. This is generally well understood within the medical community, but patient and provider education remains important.

“Men presenting with low testosterone during their reproductive years should undergo a careful evaluation to distinguish primary from secondary hypogonadism, with lifestyle interventions serving as the foundation of treatment when potentially reversible secondary causes are identified,” he explains.

Low testosterone as a marker for metabolic health

Regardless of fertility goals, weight management tends to be one of the most significant factors in addressing low testosterone. “The science is very clear,” he says. “The primary risk for low testosterone in adult men is weight gain, specifically visceral adiposity.” The following features of metabolic syndrome are closely linked to the likelihood of low testosterone.

· High blood sugar

· High triglyceride levels

· Low HDL cholesterol

· Elevated blood pressure

· Visceral adiposity

Dr. Paulos begins with a thorough patient history, investigating physical and mental health and how social determinants of health play a role. A discussion about sleep quality and quantity is particularly important, as men who do shift work or have sleep disorders are more likely to present with low testosterone.

Supporting lifestyle interventions, with or without medication

Dr. Paulos personalizes pharmacological and nonpharmacological treatment plans based on symptom severity, as well as the patient’s motivation and willingness to engage in lifestyle change.

For many patients, even modest improvement in diet, exercise and sleep can meaningfully improve testosterone levels and symptoms. For men with more severe cases or an inadequate response to lifestyle interventions, treatment options may include medications that stimulate endogenous testosterone production or testosterone replacement therapy.

Often, a short course of a testosterone-stimulating agent like enclomiphene can be paired with lifestyle interventions to restore endogenous testosterone production to give patients enough of a runway to build healthier habits before eventually tapering the medication.

“When there’s a deadline and a sense of accountability, men are more likely to follow through on lifestyle changes,” he says.

He has also assembled a standard set of resources, including films, books, websites and food-tracking apps, to help motivate patients and support adherence to lifestyle interventions. Healthy lifestyle messaging can be especially effective when it is reinforced by peers or role models, he says, rather than coming from a physician alone.

Keep an open mind about screening, especially when comorbidities are present

The conversation around testosterone has captured the attention of many men, who are now more willing to bring these concerns to their providers. Although population screening and case finding are not recommended by guidelines, men with obesity, diabetes or sleep disorders should be questioned about symptoms and screened when necessary due to the higher prevalence in those populations.

For any patient who raises concerns about low testosterone, he encourages providers to remain open to the discussion and consider its broader implications. These concerns can create an opportunity for more nuanced conversation and may uncover other health issues.

“Maybe they are depressed, have a sleep disorder, are under a lot of stress, or simply don’t feel well,” he says. “They might not have the vocabulary or awareness to identify those issues directly, but they might say, ‘I think I have low testosterone.’”

A multidisciplinary approach to men’s health

Patients often present with a specific concern, but Dr. Paulos and his colleagues in Cleveland Clinic’s Men’s Health Program take a broad, whole-person approach before narrowing in on the presenting concern.

The program includes sexual health and reproductive specialists, general urologists, internal medicine physicians and psychologists.

“Our unique backgrounds and training allow us to step back and view a man’s health in a more global fashion,” he says. “That is unique about the approach that we have here.”