Symptoms of Low Testosterone: How to Recognise Them

"Doctor, lately I have no sex drive, I wake up unrefreshed and I can't lift like I used to. Is my testosterone dropping?" I hear this almost every week. For some men the answer is yes, but for many others it turns out to be sleep, stress, depression or undiagnosed diabetes. This article helps you understand which symptoms point towards low testosterone and what to do next.

What is testosterone deficiency?

Testosterone deficiency (male hypogonadism) is when the body doesn't make enough testosterone to the point of causing symptoms. In Thailand it is often called "male menopause" (andropause), but unlike menopause in women it doesn't happen to every man, and it isn't caused by age alone.

International guidelines from the AUA, EAU and Endocrine Society agree that a diagnosis requires both of two things: symptoms, and a genuinely low blood level on repeated morning testing. If only one is present, it doesn't count as the condition. If you are unsure about normal levels, read Testosterone basics first.

Common symptoms, grouped by how specific they are

Sexual symptoms (the most specific)

• A clear drop in sex drive compared with how you used to be
• Fewer or no morning erections
• Erections that are not fully firm or don't last
• Less semen

The EMAS study in European men found that the first three symptoms were the group most closely linked to low testosterone.

Physical symptoms

• Tiring easily, less strength
• Losing muscle, gaining belly fat
• Breast enlargement or tenderness (gynaecomastia)
• Beard and body hair growing more slowly
• Thinning bones, or fractures more easily than expected for your age
• Hot flushes and sweating (in men with very low levels)

Psychological symptoms

• Irritability, low mood, lack of motivation
• Poorer concentration and memory
• Poor sleep

These psychological symptoms overlap a great deal with depression. If you feel persistently sad, lose interest in everything or have thoughts of harming yourself, read Depression or low testosterone: how to tell them apart and seek help immediately. In Thailand you can call 1323, the free 24-hour mental health hotline (Thai language; ask for English support).

Sexual

Most specific

• Clearly lower desire
• Fewer or no morning erections
• Erections not fully firm

Physical

• Tires easily, less strength
• Less muscle, more belly fat
• Breast enlargement, thinner bones

Psychological

Overlaps with depression

• Irritable, unmotivated
• Poorer focus and memory
• Poor sleep

EMAS study: the first three sexual symptoms were most strongly linked to low testosterone.

Similar symptoms that may not be hormonal

Often two things happen together. For example, belly fat lowers testosterone, and lower testosterone in turn adds fat. Care therefore has to look at the whole picture, not just the number. If your main problem is erections, starting with Erectile dysfunction (ED) is more direct, and if it is lower desire, see Low sexual desire, which covers both women and men.

Who is at risk?

• Men aged 45 and over, especially with chronic illnesses
• Waist over 90 cm, type 2 diabetes, high blood pressure, fatty liver
• Loud snoring, sleep apnoea
• Long-term use of opioids or steroids
• Having used steroids for muscle building and then stopped
• Previous injury, surgery, radiotherapy or chemotherapy affecting the testicles
• Pituitary disease or genetic conditions such as Klinefelter syndrome

How much do questionnaires help?

Questionnaires such as ADAM or AMS help men feel able to talk about symptoms and can be used to track treatment, but their accuracy for screening is fairly low. Many men answer "yes" even though their hormones are normal. So they are a starting point for a conversation, not a way to decide on treatment.

If you suspect it, what should you do?

1. Note when the symptoms started and what changed in your life at that time, such as work, weight, medicines or sleep.
2. Have a total testosterone blood test in the morning, between 7 and 10 a.m., while fasting.
3. If it is low, repeat it on another day, with LH, FSH and SHBG as the doctor considers appropriate.
4. Check for related conditions, such as blood sugar, cholesterol, blood count and thyroid, depending on symptoms.
5. Fix what can be fixed first or at the same time, such as losing weight, treating sleep problems and adjusting medicines.

A detailed list of tests is in Blood tests before starting TRT.

1. 1Note symptomsWhen they began, what changed in your life
2. 2Morning blood testTotal testosterone 7-10 am, fasting
3. 3If low, repeatAnother day, with LH, FSH, SHBG as your doctor decides
4. 4Look for conditionsGlucose, lipids, blood thickness, thyroid
5. 5Fix what can be fixedWeight loss, sleep, medicine review

Diagnosis needs both symptoms and repeatedly low morning blood levels (AUA, EAU, Endocrine Society).

When to see a doctor, and how the clinic can help

See a doctor when sexual symptoms together with other symptoms have lasted more than 2–3 months, or if you have breast enlargement, shrinking testicles or difficulty conceiving. See a doctor sooner if you have headaches with blurred vision, or milky discharge from the nipples, which may be signs of pituitary disease.

At Dr. Kris Clinic I assess the physical, psychological and relationship sides, arrange blood tests at the right time and explain the results clearly. Only if you genuinely meet the criteria do we discuss TRT: who it suits and how to start. If you don't, I will help you find the real cause. You can consult at the clinic in Surat Thani or online, and consultations in English are available.