Bryant Stamford, Special to Courier Journal Published 6:49 a.m. ET May 17, 2018 | Updated 6:50 a.m. ET May 17, 2018

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Millions of middle age and older men feel themselves slowing down and they wonder, is it simply age or is it something more, like a low testosterone level? If your testosterone is low, is testosterone replacement therapythe answer?

This seems like a simple question. Unfortunately, its not. The diagnosis process is challenging, plus there is the issue of safety. Yes, TRT can downplay symptoms, but at the same time can it be harmful? Lets take a look.

Testosterone is responsible for governing many important functions in the male body. Production typically peaks in early adulthood, then declines at the rate of about 1 percent per year from about age 35. As testosterone production in the testicles declines, muscle and bone mass are lost and body fat increases around the midsection. Red blood cell production may decline, along with a drop in libidoand sperm production, plus erectile dysfunction. When testosterone drops substantially, there can be disruption of sleep and increased lethargy throughout the day, depressed moods, lack of motivation, poor concentration and loss of memory.

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These symptoms become more obvious as testosterone levels go lower and lower. This raises the question: Is it time for TRT? That depends. How many symptoms do you have (very few men will have all of them)? Beyond that, how severe are the symptoms and how persistent? Next, how low is your testosterone level?

Testing for testosterone levels in the blood and using results for a diagnosis is not as straightforward as it might seem. Results can vary for a number of reasons, and its best to conduct tests on more than one day. But its more complicated than that because testosterone circulates in the bloodstream in three forms.

First is free testosterone that is readily available for use by the body. Second is testosterone loosely bound to albumin (a protein in the blood) which can be used but is not as immediately available as free testosterone. And third, most of the testosterone is bound tightly to another protein, sex hormone binding globulin (SHBG). Testosterone bound to SHBG is not available, but it is important because it regulates the amount of free testosterone in the blood.

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Doctors use two tests. One is for total testosterone, and the other is for free testosterone. Total testosterone includes all testosterone (free testosterone as well as all the testosterone bound to the two proteins in the blood, albumin and SHBG). As to which test is more useful and reliable, some experts believe free testosterone is the better indicator of clinical status. Unfortunately, this is not true for all patients. Also, some experts contend that free testosterone results can vary too much from day to day.

Another problem is, you can have symptoms of low testosterone even though your free and total testosterone levels are in the normal range. Whats more, although symptoms become more likely with decreasing levels of testosterone, according to the Endocrine Society of the United States, there is no clear-cut testosterone threshold that can be reliably applied to all patients.

Obviously, getting an accurate diagnosis and deciding whether or not TRT is right for you is complicated. For that reason, experts urge working with an experienced physician who fully understands the complexities associated the issues and with testosterone tests. I have found that seeing a urologist is a good way to go. Since folks always ask me, let me put in a plug for my urologist, Dr. Greg Steinbock. Hes really on top of things, plus hes a good listener and communicator.

Overall, its very important that your doctor sees the big picture, because its possible that symptoms are caused by something other than low testosterone levels. For example, obesity and being sedentary may be the root cause of lack of energy, a low libido and other symptoms.

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There is no one right approach to obtaining an accurate diagnosis and subsequent treatment, but some experts suggest assessing the impact of a trial dose of TRT for three to six months. In other words, the patient is closely monitored while taking a low dose of testosterone to see if it alleviates symptoms. One problem with this is the potential for a placebo effect, feeling better because you know you are being treated, but this usually doesnt last long.

The bottom line is, unlike prescribing medications for high blood pressure or high cholesterol, your doctor may be hesitant to have you quickly jump on board and start TRT. Instead, smart money says take a cautious approach and cover all the bases before proceeding.

Next week I will discuss potential health risks and benefits associated with TRT, and alternative treatments for low testosterone levels.

Reach Bryant Stamford, a professor of kinesiology and integrative physiology at Hanover College, at stamford@hanover.edu.

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What you should know about testosterone replacement therapy