Testosterone deficiency is seen to occur in both men and women with HIV;
Endocrine abnormalities, including the synthesis of testosterone, have long been recognized as a complication of HIV since the earliest days of the pandemic, although it has generally been associated with late-stage disease (particularly HIV wasting syndrome).
In men, testosterone is the steroid hormone which is central to the development of the testes (testicles) and prostate, as well as the promotion of secondary male sexual characteristics (e.g. lean muscle mass, bone mass, hair growth).
Testosterone is also important to women in maintaining normal muscle and bone mass, although at levels around 10% less than men. In both men and women, testosterone is essential to a person’s overall health and well-being, contributing to an individual’s strength, energy levels, and libido (sex drive).
By contrast, testosterone depletion is associated with:
- Loss of lean muscle mass
- Anemia
- Osteoporosis
- Insulin resistance
- Increased lipids (fat and/or cholesterol) in the blood
- Increased subcutaneous fat in the abdomen
- Testosterone Deficiency in HIV-Positive Men
Testosterone deficiency in men with HIV is largely associated with an endocrine abnormality called male hypogonadism, in which the function of the male gonads (testes) is impaired, resulting in the diminished production of sex hormones beyond what would be expected of a man’s specific age.
In the general population, hypogonadism is known to occur in about one in 25 men between the ages of 30-50, increasing to one in 14 between the ages of 50-79. By contrast, the incidence among men with HIV is as much as five times greater.
Hypogonadism can be caused by either a defect in the testes themselves (primary) or a dysfunction occurring outside of the testes (secondary). In adult males with HIV, primary hypogonadism accounts for some 25% of cases. It can be caused by damage to the testes due to an infection (including some opportunistic infections), testicular cancer, or by physical trauma to the testes.
Secondary hypogonadism accounts for other 75%, and is most often related to neuroendocrine disturbances in which the interaction between the nervous system and endocrine system is significantly impaired. Although there are rare cases of HIV causing damage to the pituitary gland, HIV itself does not cause the impairment. Rather, hypogonadism is observed in presence of many chronic illnesses, with persistent inflammation and nonspecific weight loss seen to be associative factors. Hypogonadism can also be caused by abuse of anabolic steroids. HIV medications have not been shown to contribute to hypogonadism.
Symptoms of Male Hypogonadism
Hypogonadism in adult males is characterized by low serum (blood) testosterone levels, as well as one or several of following symptoms:
- Decreased muscle mass
- Reduced energy and stamina
- Depression, irritability, difficulty concentrating
- Enlargement of breast tissue (gynecomastia)
- Decreased facial and body hair
- Increase in abdominal fat
- Loss of bone mass (osteoporosis)
- Testicular shrinkage
- Sexual dysfunction (e.g. erectile dysfunction, reduced ejaculate, low libido, difficulty attaining orgasm)
- Testing and Diagnosis
Diagnosis is made by measuring the amount of testosterone in the blood, of which there are three different subtypes. When a test is performed, the results will reveal both a person’s total testosterone (all subtypes) and one of the three subtypes called free testosterone.
Free testosterone is simply a type of testosterone to which no protein is attached, allowing it enter cells and activate receptors that other subtypes can’t. It is considered the most accurate measure of testosterone deficiency, despite representing only 2-3% of the total population. On its own, total testosterone is considered less accurate since results can appear normal if other non-free subtypes are elevated.
Testing should be performed early in the morning since levels can fluctuate by up to 20% during the course of a day. ‘Normal’ levels are simply those within the reference range of the lab. These ranges can vary, but, for illustrative purposes, are roughly between: 250-800 ng/dL for total testosterone and 50-200 pg/mL for free testosterone.
However, assessment of ‘normal’ cannot be made by numbers alone. Testosterone levels tend to drop by about 1-2% every year after the age of 40. Therefore, what may be ‘normal’ for a 60-year-old male won’t be the same for a 30-year-old. Assessments need to be made on an individual basis with your treating doctor.
For an appointment or consultation with Dr. Gary Bellman, please contact the office or call 818-912-1899