What Causes Low Free Testosterone?

Testosterone is an essential hormone for men; it has a hand in many processes within the body. Low levels of testosterone can be incredibly damaging to your health. 

However, you can have normal testosterone levels but suffer from low free testosterone, which is equally damaging.

Below is an in-depth look at both conditions, the causes, symptoms and treatments. 

Read on to learn more. 

What Does Low Free Testosterone Mean? 

When you have low levels of free testosterone, it means that you don't have enough testosterone available to enter into the androgen receptor cells. 

Your levels of testosterone might be normal, but it might either be too tightly bound to SHBG or sex hormone-binding globulin, or too much of it might be being converted into dihydrotestosterone or estradiol. 

So low free testosterone can even be a problem for those with normal testosterone levels. 

What Does Low Testosterone Mean?

Low testosterone, or its medical name: male hypogonadism, is a recognized condition. 

This is because the testes simply do not produce enough testosterone. Low levels of testosterone can lead to low free testosterone but not always. 

What Are the Causes of Secondary Male Hypogonadism?

Secondary male hypogonadism is intricately linked to conditions that influence the hypothalamus and/or pituitary gland. This results in reduced production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), leading to lowered testosterone and sperm production. This condition is also referred to as hypogonadotropic hypogonadism.

Congenital Causes

Secondary hypogonadism can originate from birth due to certain congenital disorders, which include:

• Isolated Hypogonadotropic Hypogonadism: This condition is characterized by insufficient levels of gonadotropin-releasing hormone (GnRH) from birth.
• Kallmann Syndrome: A rare genetic disorder causing developmental loss of nerve cells in the hypothalamus responsible for GnRH production. This syndrome may also lead to an impaired sense of smell.
• Prader-Willi Syndrome: Known as a multisystem genetic disorder that results in hypothalamic dysfunction.

Acquired Causes

Aside from congenital conditions, several acquired factors can also lead to secondary hypogonadism. These factors are often related to lifestyle or other health conditions, such as:

• Hypopituitarism: This is often caused by an adenoma, disease infiltration, infection, traumatic injury, or past treatments like radiation or surgery impacting the pituitary gland.
• Hyperprolactinemia: Elevated levels of prolactin can affect hormone balance, contributing to hypogonadism.
• Iron Overload: Conditions like hemochromatosis can disrupt hormonal functions.
• Injuries and Syndromes: Damage to the brain or head, Cushing’s syndrome, and obstructive sleep apnea can all affect hormone production.
• Chronic Diseases: Liver cirrhosis, kidney failure, and HIV/AIDS are significant contributors.
• Lifestyle Factors: Excessive alcohol use, obesity, and poorly managed diabetes have been linked to hormonal imbalances.
• Medications: Various drugs, including estrogens, certain psychiatric medications, opioids, and specific treatments for prostate cancer, can interfere with hormone levels.

Understanding these causes is crucial for effective diagnosis and treatment of secondary male hypogonadism. Each factor contributes differently, and patients may experience varying degrees of symptoms, making individual assessment vital.

Understanding the Causes of Primary Male Hypogonadism

Primary male hypogonadism is a condition where the testicles fail to produce adequate testosterone levels due to various underlying issues. This condition, also termed hypergonadotropic hypogonadism, involves an increase in certain hormones that usually stimulate testosterone production, but the testicles cannot respond effectively.

Congenital Causes

Several congenital factors can lead to primary hypogonadism:

• Anorchia: This condition involves the absence of testicles at birth.
• Cryptorchidism: Known as undescended testicles, this happens when the testicles fail to move into the scrotum before birth.
• Leydig Cell Hypoplasia: In this case, the Leydig cells in the testicles are underdeveloped, affecting hormone production.
• Klinefelter’s Syndrome: A genetic abnormality where individuals are born with an extra X chromosome (XXY), which can impact normal testicular function.
• Noonan Syndrome: A rare genetic disorder that might result in delayed puberty, undescended testicles, or infertility.
• Myotonic Dystrophy: Part of the muscular dystrophy group, these inherited disorders can impair testicular function.

Acquired Causes

Certain acquired conditions are also known to affect testicular health:

• Physical Trauma: Severe injury to the testicles or their removal can impede hormone production.
• Orchitis: This is the inflammation of one or both testicles, often stemming from bacterial infections like sexually transmitted infections, or viral infections such as mumps.
• Cancer Treatments: Chemotherapy and radiation therapy targeting the testicles can adversely affect their ability to produce hormones.
• Tumors: Certain tumors can interfere with normal testicular functionality.
• Anabolic Steroid Use: The misuse of these substances can disrupt normal hormone levels and testicular function.

Understanding the underlying causes of primary male hypogonadism is crucial for seeking appropriate medical advice and intervention. While some causes are genetic, others might be environmental or related to specific health conditions.

The Role of Testosterone in the Body

Testosterone is an important hormone, and it has a hand in regulating a lot of the processes within the body. 

Testosterone has a lot to do with your performance in the bedroom, from erectile function to libido. It also helps build and maintain muscle mass, essential for working on their physique. 

Testosterone helps to stimulate the production of red blood cells in the body, and it helps to promote the formation of new bones, which is crucial when it comes to healing fractures. 

Finally, your testosterone levels can also impact your sense of well-being, as lower levels can lead to feelings of depression. 

Understanding Low Testosterone Levels

Determining what constitutes a low testosterone level can vary slightly among experts. Generally speaking, the American Urology Association (AUA) sets the benchmark for low testosterone in adults at levels below 300 nanograms per deciliter (ng/dL).

Yet, some medical professionals and researchers advocate for a more conservative threshold, identifying levels under 250 ng/dL as indicative of low testosterone. Beyond mere numbers, healthcare providers assess the presence of symptoms such as fatigue, reduced libido, and mood changes to decide if low testosterone is an issue.

Key Points to Consider:

• Standard Threshold: Typically, under 300 ng/dL.
• Alternative Viewpoint: Some experts consider under 250 ng/dL as low.
• Symptom Evaluation: Symptoms often guide final diagnosis alongside lab results.

In conclusion, while the numbers offer a baseline, the presence of symptoms plays a crucial role in diagnosing low testosterone levels.

Low Testosterone Symptoms & Causes

Having low levels of testosterone is quite common; it is estimated that around forty percent of men over the age of forty-five have low levels. However, male hypogonadism is not limited to this age group alone. In fact, it can affect individuals with testicles at any age, from birth through adulthood.

Certain factors increase the likelihood of experiencing low testosterone. These include:

• Age: The risk naturally rises as one grows older.
• Obesity: Carrying excess weight can impact hormone levels.
• Type 2 Diabetes: Poorly managed diabetes can exacerbate the condition.
• Obstructive Sleep Apnea: This sleep disorder is linked with lower testosterone levels.
• Chronic Medical Conditions: Issues like kidney dysfunction and cirrhosis of the liver can also contribute.
• HIV/AIDS: This condition is associated with a higher risk of low testosterone.

By understanding these factors, individuals can better assess their risk and seek appropriate medical advice.

However, it is hard to determine normal testosterone levels because many factors can affect your levels. Everything from your body mass index to the time of day to your nutrition, alcohol consumption, age, and any illnesses you have or medications you take can significantly impact.

Symptoms

The symptoms of low testosterone can vary due to several factors, especially age.

If you have low testosterone, you may experience a combination of the following symptoms; you won't necessarily experience them all.

• Lower Sex Drive: You might notice a decrease in your usual sex drive, possibly coupled with erectile dysfunction.

• Emotional and Cognitive Changes: A decreased sense of well-being, feelings of depression, difficulty focusing, or trouble remembering things may occur.

• Physical Fatigue: Feeling more fatigued both mentally and physically is common, often accompanied by a loss of muscular strength.

• Physical Changes: Mild anemia, a decrease in hemoglobin, or bone density changes could occur, although these are harder to self-diagnose. Additionally, you might notice thinning or a decrease in body hair, unexpected weight gain, or development of more breast tissue.

• Infertility: Men with low testosterone often experience infertility issues.

Treatment and Expectations

While there's no one-time fix for low testosterone, consistent hormone replacement therapy can significantly improve symptoms. Many find that therapy helps enhance sex drive, lifts depressive symptoms, and boosts energy levels.

Benefits of Treatment

• Muscle and Bone Health: Treatment may contribute to increased muscle mass and bone density, providing additional health benefits.

Health Risks and Considerations

• Mortality Concerns: It's important to note that individuals with testosterone deficiency face a higher mortality risk compared to those with normal levels. However, the impact of normalizing testosterone through treatment on mortality rates remains unclear. Treatment is primarily aimed at managing symptoms rather than adjusting testosterone to a specific level.

Congenital Hypogonadism

For children diagnosed with congenital hypogonadism, testosterone replacement therapy can prevent issues related to delayed puberty, setting a foundation for healthier development.

Understanding these potential treatments and outcomes can help you manage low testosterone more effectively, making informed decisions alongside your healthcare provider.

Causes

As you age, the production of testosterone naturally slows, and the level in your body tends to drop. This decline tends to start after the age of thirty and continues slowly and steadily for the rest of your life. 

Many different factors can impact your testosterone levels and several potential causes. First and foremost, an injury or trauma to the testes which has interrupted the blood supply. 

An infection of the testes can also lower your testosterone levels. 

As mentioned above, some medications or treatments can also impact your testosterone levels, most predominantly of which is chemotherapy. 

Other medications like opioids, steroids or hormones can also affect your testosterone. 

Some metabolic disorders like an excess of iron can lower your levels. A dysfunction or tumor in your pituitary gland can hinder testosterone production. 

Both acute and chronic illnesses can also be to blame. 

Alcohol abuse, cirrhosis of the liver and chronic kidney failure, all of which are somewhat related, can also suppress testosterone production. 

Inflammatory conditions and syndromes like Kallmann syndrome or Klinefelter can also be blamed. 

Finally, weight on both ends of the spectrum, from extreme weight loss to obesity, can disrupt many systems in the body, including hormone production. 

Congenital disabilities, an excess of estrogen and sleep apnea can also cause low testosterone levels, as can previous anabolic steroid misuse, hypothyroidism, pubertal delay and head trauma. 

In short, many things can affect your testosterone levels and impede your body's hormone production. 

Symptoms & Causes of Low Free Testosterone

Low free testosterone is a lot harder to pinpoint; it is difficult to assess and measure because, as mentioned above, your testosterone levels might be completely normal. 

In addition, it can present itself in a few different ways, and it has its causes. However, there is overlap between the two conditions, which can further muddy the waters and make it hard to pin down. 

Symptoms 

In general, men with low free testosterone tend to have poorer health all around. This can present itself as an increase in physical limitations. 

They have lower levels of haemoglobin too. They often report experiencing fewer morning erections, lower libido and less sexual thoughts. 

This can sometimes go hand in hand with higher levels of erectile dysfunction too. 

Lower free testosterone suffers also tend to see a decrease in their bone ultrasound measurements.

Other than a pronounced number of sexual problems, there are a lot of different symptoms of low free testosterone. 

Again, it is worth pointing out that an overlap makes it harder to differentiate between conditions. 

You might find that you have a reduced capacity for exercise, you may also suffer from body stiffness or joint pain. You can gain weight as a result of low free testosterone too. 

Your mental health can take a dive with more feelings of depression and anxiety. You might find it harder to remember things or concentrate on the tasks at hand. 

There could also be an onset of anaemia or a thinning of your hair. 

Causes

There are several potential causes of low free testosterone; there is some overlap between the causes of low free testosterone and low testosterone, which is to be expected. 

The first potential cause of low free testosterone is increased SHBG levels, which often occur naturally. Similarly, to causes of low testosterone, an injury or tumor to the testes, hypothalamus or pituitary gland can also cause low free testosterone. 

If you require surgery, radiation, or chemotherapy to treat your tumor, your treatment's side effect could be low free testosterone. 

Obesity and some genetic or medical conditions can also cause low free testosterone, as can alcoholism, steroid, opioid, or just general drug abuse. 

Some prescribed medications may also have the same effect. 

The Effects of Leaving Low Free Testosterone Untreated

If you ignore the signs and symptoms of having low free testosterone, you may be setting yourself up for much more severe health issues. 

Leaving your low free levels untreated can lead to type 2 diabetes, cardiovascular disease or heart attacks, osteoporosis and strokes. 

When considering testosterone replacement therapy, it's crucial to be aware of potential side effects. Here's a comprehensive overview:

Physical Side Effects

1. Skin Changes: Some individuals may experience acne or increased oiliness on their skin.
2. Swelling: Mild fluid retention might lead to swelling, particularly noticeable in the ankles.
3. Prostate Issues: The therapy can stimulate the prostate, potentially causing urinary problems such as difficulty in urination.
4. Breast Changes: Enlargement and tenderness in the breast area may occur.
5. Sleep Disorders: Worsening of sleep apnea is a possible concern.
6. Testicular Changes: A reduction in testicle size can be observed.
7. Skin Irritation: Those using topical forms of testosterone might experience irritation where the product is applied.

Laboratory Abnormalities

• Prostate-Specific Antigen (PSA): An increase in PSA levels, which requires monitoring.
• Blood Changes: The therapy could lead to a rise in red blood cell count.
• Fertility Concerns: A decrease in sperm count may cause infertility, an important consideration for younger individuals planning to have children.

Being informed of these possible effects can help in discussing treatment options with a healthcare provider.

Treatment Options for Low Testosterone

Low testosterone, or male hypogonadism, can be managed through various testosterone replacement therapies. These therapies come in different forms, each offering a unique method of administration and benefit. Here's a breakdown to consider:

1. Topical Solutions

• Skin Gels: Applied daily to clean, dry skin, these gels are popular due to their ease of use. Care must be taken to avoid skin contact with others soon after application.
• Patches: Placed on the skin daily, these patches require rotation of application sites to minimize irritation.

2. Injections

• Intramuscular Injections: Administered every one to two weeks, these can be self-injected or given by a healthcare provider. Long-acting options are also available, requiring injections less frequently, approximately every 10 weeks.
• Subcutaneous Injections: A less frequent alternative to intramuscular injections, offering consistent testosterone delivery.

3. Implanted Pellets

• Pellets: Implanted under the skin, these provide a steady hormone dose for three to six months, reducing the need for frequent treatment.

4. Oral and Nasal Applications

• Buccal Tablets: These are dissolved on the gums twice daily, allowing quick absorption into the bloodstream.
• Nasal Gel: Administered by applying it into each nostril multiple times a day, providing rapid absorption.

5. Oral Medication

• Pills: Undecanoate is an oral testosterone option, especially for those with certain conditions like Klinefelter syndrome or damage to the pituitary gland.

Considerations Before Starting Therapy

Before embarking on testosterone replacement therapy, it's crucial to evaluate any potential health risks. Conditions that may contraindicate treatment include:

• A history of prostate cancer or unexplained prostate lumps, as thorough screening is required beforehand.
• Breast cancer.
• Cases of uncontrolled heart failure.
• Untreated obstructive sleep apnea.

Always consult with a healthcare provider to determine the most suitable treatment plan for your specific health needs and conditions.

The Diagnosis Process 

It can be difficult to diagnose either low testosterone or low free testosterone. The first step is consulting your doctor and telling them of your concerns. They can then advise you on the best course of action.

To start, a healthcare provider will likely perform a physical exam, assessing your overall health and looking for any physical signs related to low testosterone. They’ll also ask about your medical history, including any medications you currently take or have taken in the past, as well as your smoking history and any symptoms you may be experiencing.

Following this, they will typically order a blood test to determine whether your testosterone levels are within the normal range. This step is crucial and may need to be repeated several times, as testosterone levels can fluctuate naturally throughout the day.

If your blood test results indicate low testosterone levels, your doctor can discuss potential treatment options with you. However, if the levels appear normal, further testing might be necessary to check for low free testosterone, which requires a different approach to diagnosis.

By considering both your specific signs and symptoms along with the blood test results, your healthcare provider will work to deliver an accurate diagnosis, ensuring that all aspects of your health are taken into account.

Is it Preventable?

In short, no. There are no known preventative measures that you can take to prevent your testosterone levels from lowering. 

Frequently, a lower level is caused by a genetic condition or some form of damage to the testes or pituitary gland, which would be incredibly difficult to avoid. 

Committing to a healthy lifestyle can help keep your levels within the normal range. 

There are several natural ways to boost your testosterone. Including stress management, you are getting enough sleep and eating well. 

In addition, if you do suffer from low free testosterone, then boosting your levels, whether they fall into the normal range or not, can help to increase your free testosterone. 

You may even want to try testosterone boosters as a way to encourage your body to produce more testosterone naturally. 

In Conclusion

Low levels of testosterone free or otherwise can have detrimental effects on your health in several aspects. 

The symptoms of both conditions are far-reaching. 

If you notice any of the symptoms listed above, you should reach out to your doctor for some tests. Regular follow-up appointments are crucial if you're undergoing hormone replacement therapy, as they help monitor your progress and adjust treatment as needed.
Additionally, if you experience a drop in sex drive or start having hot flashes, these could be signs of low testosterone, and it's wise to talk to a healthcare provider. They can evaluate your symptoms and may order blood tests to get a clearer picture of your hormone levels.
For parents, if your child assigned male at birth hasn't shown signs of puberty by age 14, it's important to consult their pediatrician. Early intervention can make a significant difference in addressing any underlying issues.