Much of the conversation on this blog is dedicated to women and what happens when they have hypothyroidism or low thyroid function.
But what about men?
Do men react the same way? Do they have the same symptoms? Is treatment the same?
It turns out that the answer to each of these questions is ”No”.
In fact, the treatment, diagnosis, and management are quite different.
Hypothyroidism in men deserves special attention because of how thyroid hormones interact with their main sex hormone: testosterone.
In this post we will discuss:
- The complete list of thyroid symptoms in men
- How thyroid hormone lowers testosterone
- Why men get misdiagnosed more frequently than women
- The difference in treatment between men and women
- Basic hormone replacement therapy for thyroid hormone and testosterone
Let’s dive in…
Men vs Women and Hypothyroid Symptoms
As I’ve mentioned above men and women present with different signs and symptoms of hypothyroidism.
The problem with men is that many of their presenting signs and symptoms get lumped into the general category of “age-related” decline in health.
Meaning that doctors may dismiss their symptoms as a “normal” part of aging.
The truth is that these symptoms are far from normal, and the presentation of any of these symptoms absolutely warrants further workup.
Below I’ll go over the most common symptoms that men present with and then a list of more general symptoms of hypothyroidism to help guide you.
Men with hypothyroidism commonly present with any or all of the following symptoms:
- Increase in fatigue or decreased energy levels
- Decreased libido/sex drive and other changes in sexual function including erectile dysfunction
- Inability to build muscle mass or decreased strength
- Unexplained weight gain or inability to lose weight despite using therapies that have worked in the past
- Changes in mood ranging from feeling “down” to depression
In addition to these symptoms men usually present with 1 or more of the following general symptoms of hypothyroidism:
- Constipation or change in bowel movements trending towards constipation
- Dry skin or changes in skin texture
- Other mood changes including anxiety
- Difficulty with sleeping or insomnia
- Inability to tolerate cold temperatures
- Issues with fertility
- Muscle aches/pains, joint pain, and/or back pain
- Difficulty with concentration decreased attention span and “brain fog”
Many of these symptoms tend to be non-specific in nature, and if you only present with 1-4 of these symptoms it’s easy to see how they can easily get dismissed.
In women presenting with these symptoms, Doctors tend to prescribe anti-depressants.
In men presenting with these symptoms, Doctors tend to suggest that these are normal symptoms.
In reality, these symptoms are far from normal, and the proper treatment may dramatically improve your performance and/or reduce your symptoms.
We will talk about how to properly test for hormone imbalances and what to do if you have these symptoms, so just sit tight for a second because we need to talk about an important difference between men and women:
Why do men and women have different presenting symptoms?
Low circulating levels of thyroid hormone in the body certainly are a big issue by themselves, but the more important part of low thyroid hormone is how it interacts with other hormones in the body.
The one we are focused on in men is Testosterone.
In men, low circulating levels of thyroid hormone (or even cellular resistance to thyroid hormone) can directly lead to low levels of testosterone.
You may have noticed that many of the presenting symptoms of hypothyroidism mirror the presenting symptoms of low testosterone.
This is because the two conditions tend to accompany each other.
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The Connection between Low Testosterone and Low Thyroid Hormone
Studies have shown (1) that thyroid hormone interacts with multiple endocrine systems.
Women also experience this alteration in sex hormones (2) but they predominately experience symptoms related to estrogen/progesterone imbalance (which can be more difficult to treat than low testosterone in men).
The reason each present with unique symptoms has to do with how those sex hormones function in the body.
As a man, testosterone is your primary sex hormone.
Having normal testosterone levels is felt to be protective against many diseases (3), helps men build and maintain muscle mass (4), helps prevent cardiovascular disease (5), and is generally considered to improve longevity and quality of life (6).
Because of how important testosterone is for male health, it’s a huge deal when men have sub-optimal levels that need to be addressed immediately.
Studies have also shown that replacing thyroid hormone tends to cause a general increase in testosterone levels but I’ve found that to be less accurate in males > 40-50 years old.
In men, it is well established that both insulin resistance and hypothyroidism can act to reduce testosterone in males.
The problem is that low thyroid hormone potentiates insulin resistance (7) in men as well.
In addition, hypothyroidism promotes weight gain which further impairs testosterone production (8)…
This leads to a combination of hormones and metabolic changes that fight to keep testosterone levels low and symptoms high.
In this setting, replacing thyroid hormone may improve testosterone levels slightly, but it does nothing to treat insulin resistance.
How do you know if you have low testosterone and low thyroid hormone?
Both conditions can be tested for quite easily using standard lab tests which we will go over below.
Complete Thyroid Lab + Hormone Panel for Men
It’s important to note that standard and conventionally trained physicians may not be experienced in thyroid hormone replacement or testosterone replacement therapy.
In order to receive the proper treatment you may ultimately need to seek out a provider who understands these hormone interactions and can treat them accordingly.
If you’ve experienced any of the symptoms highlighted above then consider this thyroid lab panel + complete hormone panel as a means to get started:
- TSH: Should be < 2.0. Men frequently present with symptoms with a TSH in the 2-5 range that often goes undiagnosed but this level often correlates with subclinical hypothyroidism (9). The combination of low testosterone + subclinical hypothyroid TSH levels leads to symptoms frequently.
- Free T3: Should be in the upper 50% of the reference range. Note that men tend to tolerate lower levels of T3 when compared to women but still need T3 for optimal function.
- Total T3: Should be in the top 50% of the reference range.
- Reverse T3: Should be < 15 by standard labs. Higher levels often indicate poor thyroid conversion and are associated with high-stress levels.
- Sex hormone binding globulin: In men, this should be between 20-30, too much SHBG will bind up testosterone and limit free and active testosterone leading to symptoms. Thyroid hormone and estrogen both increase this value.
- Free Testosterone: Generally this number should be in the upper 1/3 of the reference range provided, this represents the active testosterone in the serum.
- Total Testosterone: Optimal levels are generally > 600-700 (depending on the reference range), but note that this number is highly variable between men. If your body is used to a 1,200 testosterone level and you suddenly drop to 600, this value may seem “normal” but in reality, it’s not for your body.
- Estradiol: This should be < 30. Higher levels increase SHBG and bind up testosterone leading to issues like erectile dysfunction, etc.
This set of labs will provide you with a great starting point but a complete lab panel should also include other factors like inflammatory markers, cholesterol & lipid profile, and other basic blood tests.
The reference ranges provided above are different from the auto-generated lab reference ranges on typical lab slips so base your results on the “optimal” ranges listed above.
After treating many patients with hypothyroidism and other hormone imbalances I’ve found that men (ages 40-50) with hypothyroidism generally present with lab values in the following ranges:
- TSH: Usually between 2-5
- Reverse T3: Generally > 20
- Free T3: Often at the low end of the reference range
- Testosterone: Generally between 200-300
- Hgb A1c: Generally > 5.7
- Fasting insulin: Generally around 10
- SHBG: Generally low (15-20)
- Estradiol levels: Generally > 35
This is just to give you an idea of what may be deemed “normal” by providers but in reality, is very suboptimal and will present with symptoms (noted above).
You can see from the example above several problems with this profile:
- TSH of 6.192 (outside of the reference range in this case) which is way too high and indicates hypothyroidism right off the bat
- Low testosterone at 497 (suboptimal for this particular patient)
- Low Free T4 at 0.58 with a reference range of 0.89 to 1.76 (again indicating low circulating levels of thyroid hormone)
- Elevated antibodies with thyroglobulin antibodies at 2075 and thyroperoxidase antibodies at 232 are concerning for Hashimoto’s thyroiditis or autoimmune thyroiditis
- High Hgb A1c at 5.7 indicates impaired fasting insulin
- High estradiol at 43.1 contributes to symptoms
This patient had a great improvement in symptoms once treated with both testosterone and thyroid hormone replacement which we will discuss below.
Testosterone + Thyroid hormone Replacement Therapy
In addition to presenting with different symptoms than women, men often require slightly different treatment.
Thyroid hormone (in conjunction with other hormones) helps to regulate the metabolism of the entire body.
Because males tend to have higher resting energy expenditures (10) (AKA metabolism) than women, men often require higher doses of thyroid hormone.
In addition, thyroid dosing tends (at least somewhat) to be dependent upon total body weight (11).
As a result, men tend to require higher doses of thyroid hormone than women.
While it is true that each person is unique, I have found that this tends to hold true for men.
They tend to also take longer to notice the effects after supplementing with thyroid hormone as well.
Women may notice changes in symptoms within 4-6 weeks, but in men, it tends to require 8+ weeks for these changes to be noticed (using subjective symptoms as a guide).
As a general rule, I have also found that men tend to tolerate T3-containing medications (and often do better on these medications) than most women.
If you are a man currently taking a thyroid hormone, and not noticing any changes to your symptoms, it might be worth considering changing medications to something containing T3 hormone or simply increasing your dose.
These formulations have T3 in them which is the active thyroid hormone.
You can read more about T3 vs T4 medications in the links above.
In addition, it’s important to remember that some of your symptoms may overlap with other hormone imbalances.
I’m specifically talking about low testosterone.
If your symptoms have not improved with thyroid hormone replacement then it would be worth evaluating testosterone and other hormone levels and replacement of these hormones as necessary.
Final Thoughts & Recap
Hypothyroidism, while more common in women, should not be overlooked in men.
The consequence of low circulating levels of thyroid hormone in the body impacts other important hormone systems in men – especially testosterone levels.
What’s also important is that these low levels of testosterone may not improve with thyroid hormone replacement therapy.
Men also may require a higher total dose of thyroid hormone and may require more T3 when compared to women.
Ultimately if you are being treated for hypothyroidism as a male and not improving, consider checking other hormones and/or changing/altering your thyroid medication.
Are you suffering from hypothyroidism?
Is your thyroid hormone replacement helping?
Do you think it may be lowering your testosterone levels?
Why or why not?
Leave your questions or comments below!