Raising levels of testosterone may help some men manage Type 2 diabetes

SINGAPORE: Testosterone may not only affect a man's appearance and sex drive, it may also be a factor in managing metabolic diseases like Type 2 diabetes.   

When a man has testosterone deficiency, increasing the level of the male hormone could increase insulin sensitivity, which could in turn improve his sugar level, according to urologist Dr Joe Lee.  

"An appropriate level of testosterone can help improve insulin sensitivity and provide better sugar control. At the same time, with his fatigability reduced, it is easier for the patient to start exercising and succeed in weight control," he said. 

Fatigability, or the tendency to feel tired all the time, is one of the symptoms of testosterone deficiency, which is defined by a persistently low level of the hormone. Other symptoms include sexual dysfunction, poor memory and concentration, as well as mood swings.

Men who show such symptoms while living with diabetes should have their testosterone level checked, Dr Lee said. Twelve is considered a normal level for total testosterone, he added.

Dr Lee, director of Andrology & Male Reproductive Medicine at the National University Hospital, said that between 15 and 25 per cent of men with diabetes may have low testosterone, based on published data. 

“I do recommend that doctors managing diabetes patients check the testosterone levels of patients who have significant symptoms of testosterone deficiency such as fatigability, weakness and reduced sexual function,” Dr Lee said.

Another group of patients who should get checked are those who face “great challenge” getting their diabetes under control despite dietary restrictions and medications, he added.

However, Dr Lee stressed: “We do not recommend checking the testosterone levels of every diabetic man, to avoid over-testing the men who do not have a testosterone problem." 

TREATMENT OF TESTOSTERONE DEFICIENCY 

When low testosterone is first detected, patients are advised to adopt some lifestyle adjustments like being more active and eating healthily. 

“If lifestyle modification does not show an improvement in the testosterone levels or symptoms, testosterone replacement therapy can be considered,” Dr Lee said.

Testosterone replacement is commonly done through testosterone injections every three months, testosterone gel or testosterone tablets.

Dr Lee stressed that testosterone therapy is not the main treatment for diabetes, but an "adjunct" treatment.

“The patients who benefit have to be patients who are proactive in managing their lifestyle and risk factors. It cannot be left to just testosterone. It’s not a wonder drug,” he said.

Dr Vivien Lim, an endocrinologist who runs a clinic in her name at Gleneagles Medical Centre, said that weight issues are associated strongly with the central suppression of testosterone. At the same time, diabetes itself also can affect nerves and cause erectile dysfunction.

"It is not surprising then that many patients with diabetes present with sexual dysfunction and symptoms that are due to low testosterone levels," she said. 

"This is at times, unfortunately, ignored and not screened for. As part of overall management of diabetes, this aspect should also be given its due consideration." 

However, Dr Lim said that whether or not the patient has low testosterone levels, the diabetes "can still be and should be adequately controlled". 

"We have so many drugs now for diabetes, with more coming out as we speak," said Dr Lim, who is also president of the ASEAN Federation of Endocrine Societies.

BENEFITTING FROM TESTOSTERONE THERAPY

Dr Ronny Tan, consultant urologist and andrologist at Advanced Urology Associates at Farrer Park Hospital, said that up to 30 per cent of men who see him for testosterone deficiency would also be diabetic. 

"When the levels of testosterone reach normal levels after treatment, these men are symptomatically better and when I review the HbA1c of some of these patients, they do show improvement," he said, referring to the measurement of how well the blood sugars have been controlled in the three months prior to the blood test.

One patient who has benefited from testosterone treatment is civil servant Muthu Karuppiah, who was diagnosed with high cholesterol, diabetes and high blood pressure about 20 years ago.  

While he was able to maintain his cholesterol and blood pressure at reasonable levels with medication, the same did not happen for diabetes. 

He would start on a type of medication, which helped keep his sugar level under control for some time, but although his efforts to exercise and control his diet did not change, his hbA1c level would start creeping up again. 

“It was depressing and demoralising, and of course, I get a lot of lecture from the professor (his doctor),” said Mr Muthu.

He was put on more types of medication, and with increased dosage. However, their effects continued to be temporary and he had to start on insulin injections.  

Mr Muthu was generally conscientious about his weekly walks until three years ago when he could not bring himself to continue. He was also feeling too tired.  

“I know I need to exercise, but the drive wasn't there, the motivation wasn't there. I always procrastinate, you know, say ‘okay I'll do it tomorrow, tomorrow, and that tomorrow never came,” he said. 

Mr Muthu incidentally visited Dr Lee for weak bladder issues in February last year. Given his symptoms, Dr Lee ordered a testosterone test for his patient, which showed that he had a low testosterone level of 6, below the normal level of 12. 

When given the choice to start testosterone replacement therapy, Mr Muthu opted for regular testosterone injections. The difference in his energy level was “almost immediate” following his first jab, he said.

“I started working out and then I went on on that following day without feeling any tiredness,” he said. 

Save for a knee surgery that set him back for a while, Mr Muthu has been walking 12km five times a week.

According to this doctor, his hbA1c level is reasonably good now. And the difference in his demeanour has not gone unnoticed.

“Friends whom I meet after some time, they say ‘I see a lot of change in you, you look more lively’,” he said. 

Dr Lee advised men with diabetes who experience symptoms of low testosterone to request a check to see if their testosterone levels are indeed low. The condition is not easily detected, he said. During a typical consult with a doctor for diabetes, symptoms of testosterone deficiency would be considered “by the way”, he added.

In order to detect patients with testosterone deficiency, Dr Lee suggested that it will be good if both doctors and patients play an active role in talking about it.

“If you don’t bring it up, and the doctor doesn’t ask, it (testosterone deficiency) may be missed out,” he said.