Testosterone: Symptoms & Testing
Most men who lose one testicle to testicular cancer continue to make enough testosterone with the remaining testicle. But some do not, and hormone problems can also develop years later. This page is for men who have already lost a testicle and feel different, for partners who have noticed changes, and for anyone whose remaining testicle may not be functioning normally.
If you are reading this before orchiectomy and want to know what hormone information is worth getting before surgery, see the
Orchiectomy page. Men facing removal of their last functioning testicle should also read
TC Twice.
What Might Low Testosterone Look Like?
Low testosterone does not always announce itself as a sexual problem. Some changes are easy to miss, and sometimes a spouse or partner notices that something is different before the man does.
Changes you or your partner might notice include:
- Fewer or no morning or spontaneous erections
- Less interest in sex or fewer sexual thoughts
- Problems getting or maintaining erections
- Unusual fatigue or loss of energy
- Increased irritability
- Becoming unusually short-tempered or argumentative
- Depressed mood
- Difficulty concentrating or feeling mentally foggy
- Hot flashes or unusual sweating
- Loss of muscle or strength
- Increased body fat
- Reduced facial or body hair over time
Sometimes the first clue is something less obvious. Longstanding testosterone deficiency can contribute to low bone density and anemia. The problem may first come to attention after an unexpectedly low bone-density scan, an osteoporosis-type fracture or an unusual fracture for the circumstances, or otherwise unexplained anemia.
A partner may notice first. A gradual drop in sex drive can be surprisingly easy for the man himself to miss because he simply feels less interested. A partner may instead notice less sexual interest, less energy, more irritability, a shorter temper, or a general sense that he does not seem like himself.
None of these changes proves that testosterone is low. Sleep problems, depression, medications, thyroid disease, anemia, diabetes and many other conditions can cause similar symptoms. The point of testing is to find out whether testosterone deficiency is actually part of the problem.
How Testosterone Should Be Tested
One testosterone measurement can clearly reveal a problem if it is profoundly low, but a single result often does not tell the whole story. Testosterone changes during the day and from day to day, and a result that falls inside the laboratory's reference range does not automatically prove that testicular function is normal for that man.
- Start with an early-morning total testosterone. Current endocrine guidance recommends a morning blood draw, preferably fasting.
- Repeat it on a different morning when the diagnosis is not already obvious. Formal diagnosis of testosterone deficiency generally relies on symptoms plus consistently low testosterone on separate measurements. A profoundly abnormal result should still be taken seriously while it is being confirmed and explained.
- Use a reliable laboratory. Testosterone assays are not perfectly standardized. When possible, comparing results from the same laboratory and assay makes trends easier to interpret.
- Do not overinterpret a result drawn during an acute illness. Significant illness, poor nutrition and some medications can temporarily lower testosterone and complicate the picture.
Total Testosterone Is Only Part of the Picture
LH, and sometimes SHBG/free testosterone, can add important information even when the total testosterone is not flagged as low. This is especially relevant after losing one testicle.
- LH (luteinizing hormone): especially important after testicular cancer. LH is the pituitary signal that tells the Leydig cells in the testicle to make testosterone. When the hormone feedback reaching the brain is not sufficient, LH rises. A high LH with a low testosterone points toward primary testicular failure. A high LH with a testosterone that is still inside the laboratory range means the pituitary is still signaling for more testosterone, but the testicle is not able to increase production enough to bring that signal back down. This pattern is often called compensated Leydig-cell dysfunction or mild Leydig-cell insufficiency. It should not be dismissed simply because the total testosterone is technically "in range." A low or unexpectedly normal LH with low testosterone points more toward the pituitary or hypothalamus and may lead to a different workup.
- SHBG and free testosterone: useful when total testosterone is borderline or does not fit the symptoms. An unusually high or low SHBG level can make the total-testosterone result misleading.
- FSH: more useful for understanding sperm-producing function and fertility than for deciding whether a man has enough testosterone.
- Prolactin and other tests: not needed for everyone. They become useful when the testosterone and LH pattern suggests a pituitary or other non-testicular cause.
What Does the Pattern Mean After Losing One Testicle?
A remaining testicle often compensates well after orchiectomy. Sometimes it does not fully compensate. Testosterone may still fall inside the laboratory range, but an elevated LH shows that the pituitary is still signaling for more testosterone than the testicle is able to provide. That can reveal partial Leydig-cell failure even before the total testosterone falls below the laboratory cutoff.
Your symptoms, repeated testosterone results, LH and, when needed, SHBG/free testosterone should be considered together. There are at least two ways a "normal" total-testosterone result can still hide useful information:
- Normal total testosterone, but high LH: suppose a man has symptoms, a total testosterone of 400 ng/dL, and an LH that is clearly above that laboratory's normal range. The testosterone number by itself may look acceptable, but the elevated LH says the pituitary is still signaling for more. The remaining testicle is not able to increase output enough to normalize that feedback signal. In a symptomatic man, this is meaningful evidence of impaired Leydig-cell function. Repeat results, free testosterone/SHBG, fertility plans and the overall clinical picture help determine whether testosterone treatment is appropriate even though the total testosterone is technically within range.
- Normal total testosterone, but low free testosterone: a man might have a total testosterone around 450 ng/dL but an unusually high SHBG level. In that situation, the calculated free testosterone can be low even though the total testosterone looks normal. If the symptoms fit, that can materially change the interpretation.
If You Currently Have an hCG-Producing Testicular Tumor
Beta-hCG can act like LH and stimulate the testicle to make testosterone. An hCG-producing tumor can therefore raise testosterone and suppress LH, making the hormone picture harder to interpret.
This is not only a concern when hCG is in the tens or hundreds of thousands. In one testicular-cancer cohort, men with beta-hCG above 5 IU/L had a median level of 114 IU/L (middle 50% about 31 to 529 IU/L). Their median LH was only 0.1 IU/L compared with 5.6 IU/L in men whose beta-hCG was 5 IU/L or less, and their testosterone was higher. A separate published case is even more striking: with an intact hCG of only 29.6 IU/L, the patient's LH was below 0.1 and testosterone was about 2,469 ng/dL; after orchiectomy the hCG became undetectable, LH rose to 6.5 and testosterone fell to about 524 ng/dL.
Those data do not establish a precise hCG threshold at which the effect begins, and an individual result can vary enormously. They do show that hCG does not have to be extremely high to distort the testosterone/LH picture. Any clearly tumor-related hCG elevation is a reason to interpret a pre-treatment hormone panel cautiously.
If You Are Already Taking Testosterone
Once you are taking testosterone therapy, blood testing needs to be interpreted in relation to the preparation you use, the dose, and the timing of the blood draw. Go to Testosterone: Replacement Therapy for dose monitoring, including the possible role of LH while on treatment.
Before Starting Testosterone, Think About Fertility
If you still have a functioning testicle and might want biological children: tell the prescriber before starting testosterone. Testosterone treatment can suppress the pituitary hormones that drive sperm production and can reduce sperm counts dramatically, sometimes to zero.
For a testicular-cancer survivor, a semen analysis and sperm banking may be worth discussing before long-term testosterone treatment. See Fertility 101 for more information.
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