Low testosterone, aka male hypogonadism, is becoming quite an epidemic. Countless men are being prescribed testosterone replacement therapy (TRT), a form of hormone replacement therapy (HRT), to counteract the deleterious effects of testosterone deficiency.
Unfortunately, that has also led to more men who don't actually have hypogonadism jumping on TRT prematurely. Recent data suggest that androgen prescription rates in the US for men older than 60 years of age quadrupled between 2001 and 2011 .
Yet, a significant portion of men prescribed testosterone replacement therapy did not meet the clinical criteria for hypogonadism during those years. It seems younger men are following the same trend in hopes of preemptively stymieing the aging process.
While the health benefits of TRT are unequivocal for some men — helping to restore their vitality, virility, and vigor — others are needlessly taking the plunge (no pun intended). And once you've gone down that path, it's tough, if not impossible, to turn back. Your body is dependent on exogenous testosterone once you've been on TRT long enough.
So, when is it time for a man to consider testosterone replacement therapy? How does TRT work?
Read on as this guide details putative causes of male hypogonadism, why more men are seeking hormone therapy for their symptoms of low testosterone, and the pros and cons of taking prescription testosterone.
Disclaimer: The author of this article is not a licensed healthcare provider. Do not treat the content herein as medical advice. This guide is purely for informational purposes and, hopefully, illuminating other men on the topic of male hypogonadism. The views expressed below are a result of many years of post-secondary education, reviewing primary literature, first-hand experience being on TRT, and researching topics related to nutrition, physiology, endocrinology, and other health sciences.
While it’s normal for a man's testosterone levels to decline as part of the aging process, there’s population-level evidence that the rate of testosterone deficiency has been increasing over the past four decades . In fact, a recent study estimates that nearly 4 in every 5 men with obesity, type-II diabetes, metabolic syndrome, dyslipidemia, arterial hypertension, and/or chronic obstructive pulmonary disease (COPD) also have hypogonadism (low testosterone) .
Statistically, 2 out of 3 men in the United States have one (or more) of the conditions mentioned above . In other words, it’s an improbability if you don’t know any men like that. After accounting for those factors, the number of men who have clinical testosterone deficiency — defined as total testosterone levels < 300 ng/dL — is upwards of 40% (yikes!).
Moreover, roughly 5% of otherwise healthy middle-aged men (ages 19-39) suffer from hypogonadism . (Remember, that's in addition to the aforementioned unhealthy population.)
But why does it matter, you ask? Well, low testosterone goes hand-in-hand with a life full of health complications, especially cardiovascular disease — the leading cause of death globally . Research also shows that men with low testosterone are more likely to be diagnosed with impotence, metabolic dysfunction, and prostate cancer [7, 8]. What’s most worrisome is that men with low testosterone tend to die at an earlier age than those with normal/healthy testosterone levels .
Even if you’re in good health, eat a wholesome diet, and exercise regularly, it behooves you to get your testosterone levels checked, especially if you’re entering your 30s. It’s better to take action while you’re still relatively young so you don’t have to resort to testosterone therapy in the future. The sooner you take an interest in your hormonal health, the better your results will be in the long run.
Not to mention, many presumable contributors to male hypogonadism are everywhere we look.
Testosterone is the veritable "male hormone" in humans due to its androgenic properties. It engenders masculine sexual characteristic development (among various other physiological roles). Women also produce small amounts of testosterone, but nowhere near as much as men.
Testosterone is also a highly anabolic steroid hormone, meaning it stimulates “building” processes throughout the body. A notable example is how testosterone encourages skeletal muscle growth; hence, it’s the most common steroid used for performance enhancement purposes by athletes and bodybuilders.
As a man ages into his 30s, endogenous (read: the body's own) testosterone production starts to decline . This wane in natural testosterone levels is expected and usually benign.
But for some men, the effects of diminishing testosterone levels are palpable. They lose their vigor, drive, and energy levels. They struggle to build muscle and can't seem to lose belly fat no matter how hard they train or how strict their diet is. Worst yet, they often lose confidence and ability to "keep it up" in the bedroom.
Sure enough, multiple studies have found that there is a correlation between males with higher levels of testosterone, self-confidence, and displaying “alpha” (read: masculine) characteristics in social situations [11, 12, 13]. In other words, men with high testosterone levels are naturally more dominant and assured than those with lower testosterone. They also typically have more lean body mass and muscle strength .
Of course, those are just generalities. Not all men with higher testosterone are more masculine or assertive than those with lower testosterone, nor are they destined to outlive them. Nevertheless, testosterone levels are positively associated with quality of life and longevity in men . It’s not a metaphor to say that testosterone is a fountain of youth because it is!
Testosterone levels typically peak between a male’s late teens and mid-20s, followed by a steady decrease after that. A healthy adult male may lose anywhere from 0.5% - 5% or more of his natural testosterone production per year once he reaches his late 20s.
Interestingly, a recent biostatistics study that included over 10,000 healthy males between the ages of 3 and 101 years old found that testosterone levels “flatline” around the age of 40; the term “andropause” refers to this phenomenon .
The catch is that 40 is also the age where the variance of total testosterone levels between older men increases. So, just because you’re “andropausal” doesn’t necessarily mean you have clinical testosterone deficiency.
That study ultimately tells us that a normal/healthy testosterone level is highly individualistic (see chart below).
Image Credit: Kelsey et al., 2014
As it stands, the “normal range” for men over the age of 30 is about 300 ng/dL - 1050 ng/dL (10.4 nMol - 36.4 nMol/L ). Notice how wide that range is for testosterone levels in men. Some feel completely fine and dandy despite being on the lower end (red and blue dots below the curved line) of the normal range for their age.
Thus, you should not compare yourself to others when it comes to your testosterone levels. There is no “optimal” level for everyone.
So, when should you be concerned about low testosterone levels?
Image Credit: Kelsey et al., 2014
If your testosterone levels fall in the range of the bottom green and blue lines on the chart above (roughly 10.4 nMol/L <—> 300 ng/dL or less) and you are experiencing symptoms of low T, you should take it seriously. This range accounts for approximately 10% of men 30 ages or older and may indicate hypogonadism.
If your levels come back low, it’s imperative to do everything in your power to increase testosterone naturally before considering testosterone replacement therapy. Many men can optimize their testosterone levels through proper lifestyle choices. Taking a quality natural testosterone booster may also help (learn more about Transparent Labs Vitality here).
There are numerous lifestyle factors and daily habits that cause a man's testosterone levels to fall below the normal biological range for males ages 30 or older, 300-1,050 ng/dL (10.4 nMol - 36.4 nMol/L). For example, not sleeping enough and being chronically stressed out are two common factors that reduce natural testosterone levels in males [17, 18]. Excessive drinking (alcohol) and carrying large amounts of belly fat can also lower testosterone [19, 20].
Laying around on the couch all day after sitting behind a computer for 8 hours is not doing any good for your testosterone levels either . Male hypogonadism is undoubtedly more common nowadays because of the rather sedentary lifestyle that many adults lead and neglect for healthy food choices .
But even if you work out daily, you need to be mindful of the type of exercise you're doing. Heck, endurance athletes have been shown to have a mere 50% of testosterone levels as sedentary men of the same age . Heavy resistance training has the opposite effect . So, pump some iron when you hit the gym!
Okay, now for the unfortunate reality: low testosterone can't also come about due to factors that are entirely out of your control, such as prenatal exposure to alcohol, a genetic condition, pituitary gland dysfunction, or an accident that critically damages your testicles.
Furthermore, we face increasing exposure to ineluctable chemical pollutants and xenobiotics, like phytoestrogens, heavy metals, and phthalate plasticizers. They are in our food supply, drinking water, personal care products, the ambient air around us; you name it. Over time, these compounds can insidiously deplete testosterone levels [25, 26]. For example, chronic exposure to polychlorinated biphenyls (PCBs) in the environment is associated with reduced serum testosterone levels .
Though, we can't rule out that men are being more proactive about their health these days and acknowledge how important testosterone is for their well-being. Intuitively, an increase in hypogonadism diagnoses is a corollary of that.
The accessibility of testosterone therapy is also much greater now than it was in the 20th century. Low testosterone has likely been an epidemic for some time; we are simply more diligent about treating it now.
Regardless, the upheaval of men with low testosterone is by no means the natural order of things; it's ostensibly a consequence of 21st-century civilization and first-world lifestyles. In fact, hypogonadism is now one of the most common male endocrine dysfunctions across the globe .
So, does that mean you should seek testosterone treatment? Not necessarily.
If you currently follow a poor diet, barely sleep, and are sedentary, you should work on changing those habits before resorting to testosterone replacement therapy. However, if you experience symptoms of low testosterone despite leading a healthy lifestyle, you might be a good candidate for TRT (and it will be much safer).
In past decades, males were less educated about testosterone; many were not aware that hypogonadism could be contributing to their reduced vitality, lack of libido, brain fog, fatigue, and loss of motivation. Make no mistake, an occasional "lazy day" where all you want to do is hang out on the couch and watch Netflix can be a nice respite, but something is wrong when that's all you feel like doing.
Due to recent advances in our understanding of testosterone deficiency and its prevalence, endocrinologists and pharmaceutical companies alike have been strategic about direct-to-consumer marketing. Men are now more aware than ever that they should have their testosterone levels checked regularly, especially as they age into their 30s.
Naturally, that has led to rising diagnoses of men with testosterone deficiency (clinically known as male hypogonadism). But what exactly are the symptoms and signs that you have low testosterone levels? Here's an abridged list of what you might experience:
While you may exhibit several (or all) of the symptoms of low testosterone, it's imperative to confirm that you have hypogonadism (or hypopituitarism) with the appropriate blood work. Being depressed and unable to concentrate are also symptoms of mental disorders or just life in general. If you try treating your depression and brain fog with TRT (without first confirming you have hypogonadism), the health risks of using testosterone will likely increase.
As this guide will discuss later, TRT is exceptionally safe if you actually have an underlying condition that's suppressing your endocrine system. Growing older is not a "cause" of low testosterone. Having a traumatic brain injury that damages your pituitary gland might be; getting in an accident that mangles your testicles may be as well. Being chronically exposed to certain environmental toxins can also deplete natural testosterone levels.
In some cases, the cause of hypogonadism may be idiopathic. But the innate decline in testosterone levels as men age does not automatically warrant medical intervention.
Plenty of men maintain completely normal testosterone levels well into their 50s, 60s, and even 70s, albeit towards the bottom of the range. By that point, taking TRT will probably not "enhance" their life, especially if they feel fine as is.
That ties back to the point made earlier that you shouldn't compare yourself to others. The effects of testosterone vary from one person to the next. Some men are perfectly happy and healthy despite having natural testosterone levels in the lower quartile of the normal range. There is no reason for them to believe they will be "even happier and healthier" if they increase their levels to the higher end of the normal range.
If you're experiencing symptoms of low testosterone, but your levels are consistently in the normal/healthy range, TRT isn't going to solve anything; it might even lead to more health problems.
Testosterone levels naturally peak in the morning between 7 AM and 10 AM. Hence, your doctor will ask you to give a blood draw during those hours for accuracy and reliability. They may also order a handful of other blood tests to assess your overall endocrine function, such as estradiol levels, cortisol levels, and sex-hormone-binding globulin (SHBG).
Misinterpreted or inaccurate blood test results can lead to a false positive of low testosterone or potentially cause someone with hypogonadism to go undiagnosed. As such, you will likely need to confirm your initial blood work results with a follow-up blood test or two.
Remember, TRT is a life-altering treatment. Be patient, and don't jump on the bandwagon without complete confidence that low testosterone levels are causing your symptoms.
Your doctor will help interpret your lab results and answer any questions you have. If you are diagnosed with low testosterone, TRT might be prudent if the effects are impinging on your day-to-day life.
Before starting TRT, bringing your concerns to your primary care physician is wise. If you don't have an objective guideline to work with (i.e. your plasma testosterone levels), you have no way of knowing if low testosterone is causing your symptoms.
Many men are quick to self-medicate by buying testosterone "on the streets" rather than getting a prescription through a doctor. Be aware that using testosterone illicitly is dangerous for several reasons, one of which being a felony offense since it's a controlled substance in the United States.
Do it the right way: Find a doctor, preferably an endocrinologist trained in hormone replacement therapy, and have your free and total testosterone levels checked. If your levels come back low, chances are you'll be a candidate for TRT.
Take a deep breath; low testosterone is not an endpoint, nor is it something to be embarrassed about or ashamed of. We are all fighting an uphill battle against modern diseases, environmental contaminants, and increasingly stressful lifestyles.
Yet, most aging men aren’t having a discussion about their testosterone-related health concerns. Perhaps that's because there's still much societal stigma about testosterone itself? If a man takes testosterone because he has a medical condition, it’s often seen as taboo. People will say, “Oh, he’s on steroids just so he can build more muscle,” or "He's at an advantage because he's not 'natty.'"
Those are silly accusations. Maybe his body simply doesn't produce as much testosterone as it should. There is no "advantage" for someone who takes testosterone replacement therapy since the goal is to restore their levels to the normal biological range (i.e. the amount a healthy man produces).
Curiously, when a woman takes estrogen to treat menopause, people see it as judicious medical recourse (which it is). But estrogen (estradiol) is a steroid too! The cognitive dissonance between different types of hormone replacement therapy only perpetuates the misapprehension that testosterone is inherently “bad” and “dangerous”(and just so we’re clear, it’s not).
Testosterone is the most vital hormone for men. Without it, men wouldn’t be men. Just think about how driven, energetic, and vivacious you and your peers were in your teenage years and early 20s. It’s no coincidence that testosterone levels tend to peak at those ages.
The good news is that aging doesn’t mean you'll never feel like your younger self again. If anything, age is just a number, and it sure as hell isn’t an excuse to get out of shape or stop chasing your dreams. Optimizing your testosterone levels, whether naturally or through testosterone therapy, can not only add years to your life but life to your years.
Testosterone replacement therapy is a type of androgen replacement therapy designed to restore healthy testosterone levels in someone, usually an older male, who suffers from testosterone deficiency. TRT is tantamount to a person with type-1 diabetes who injects insulin; the body lacks endogenous production of a necessary hormone, so it needs to be “replaced” with an exogenous source.
In the case of TRT, this means using exogenous testosterone (generally injectable testosterone) to bring testosterone levels back to a healthy range. Other forms of testosterone prescriptions exist, such as testosterone patches and testosterone creams (both of which are absorbed through the skin instead of being injected).
Depending on the form of testosterone you are given for your treatment, you can expect to see improvement of low testosterone symptoms within a few weeks. For most males with hypogonadism, it will take closer to one month of TRT before noticing significant improvements in quality of life, sexual function, and well-being.
It’s key to remember that testosterone therapy is a long-term solution to an otherwise long-term health problem. It will not transform your body or mind overnight.
Many men have initial reservations about taking testosterone. Is testosterone treatment safe in the long run?
Long-term studies indicate that testosterone replacement therapy is much safer and beneficial if you have a confirmed diagnosis of low testosterone and ruled out confounding variables, such as a high prostate-specific antigen (PSA) reading or cardiovascular complications . A knowledgeable, licensed physician that specializes in endocrinology (or urology) can help get to the root cause of your health concerns.
To reiterate, don't assume you have low testosterone because you feel tired, depressed, unable to think clearly, or have a low sex drive. Feeling fatigued, in and of itself, is not indicative of low testosterone. Taking testosterone won't necessarily remedy your symptoms if you don't truly have low testosterone.
Always confirm the suspicion that you have low testosterone levels with proper bloodwork, and consider alternative causes if testosterone isn't the apparent culprit.
A small percentage of men experience some initial side effects of testosterone use, notably oily skin, acne, body hair growth, breast swelling or inflammation, and night sweats. These side effects tend to subside as your body adjusts to TRT and testosterone and estrogen levels stabilize.
For older men on long-term TRT, there appears to be a slightly greater risk of cardiometabolic issues, like high blood pressure and dyslipidemia (e.g. an elevated ratio of LDL:HDL cholesterol) . Your prescribing doctor should ensure that you stay in a healthy range for metabolic and cardiovascular biomarkers while on TRT, which will drastically reduce any potential health risks. Consuming a generous amount of omega-3 phospholipids daily can also help.
On the flip side, the health risks of neglecting to treat low testosterone levels are ostensibly more life-threatening than TRT itself. Longitudinal research suggests that men with low testosterone are at a greater risk of all-cause mortality (i.e. death from any cause) than those with healthy testosterone levels .
Due to advances in hormone replacement therapy and medications, like bioidentical hormones, the benefits of TRT seem to outweigh the potential risks (especially if you have very low T levels).
Sadly, there are tons of men's health clinics cropping up across the globe that are just out to make a quick buck. A guy will walk in and complain of feeling tired and unmotivated — it must be low testosterone, right? Well, not necessarily.
The symptoms of low testosterone are relatively nondescript and attributable to numerous health conditions. Treating your alleged testosterone deficiency without objective data to back it up is just being reckless, and it can have irrevocable consequences.
The decision to start TRT is not one to take lightly. Every medical treatment carries risks. Be wary of doctors and specialists who aren't thorough in diagnosing your condition. The more information you have before taking prescription testosterone, the better.
Here are some questions and concerns physicians often receive from men about TRT:
Q: Will testosterone therapy increase my risk of prostate cancer?
A: There is no compelling data to suggest that TRT will increase the risk of prostate cancer in the long run . In fact, some research shows the opposite: that men with healthy testosterone levels (which is what TRT accomplishes) are less likely to get prostate cancer than those with low testosterone .
Q: Is TRT safe if I have a history of cardiovascular complications?
A: It is a misconception that TRT raises blood pressure and LDL cholesterol . However, only you and your doctor can determine if TRT is safe for you since everyone is unique. If you have hypertension or hyperlipidemia, it's generally best to get those under control before starting testosterone therapy.
Q: Will I have to stay on testosterone therapy forever to keep my levels in a healthy range?
A: The short answer is yes. The long answer is complicated, but here goes...
Once you start testosterone therapy, the body shuts down its endogenous production of testosterone. While it is possible to "restart" your endocrine system after coming off of testosterone therapy by taking a drug that increases luteinizing hormone (LH), such as clomiphene (Clomid), or human chorionic gonadotropin (HCG), there is no guarantee that your endogenous testosterone levels will return to a healthy baseline.
Therefore, most men should think of TRT as a lifelong commitment. If you're not content with that, don't do it.
Q: What is the best form of testosterone replacement therapy?
A: There is no unanimous "best" way to take testosterone since each form has pros and cons. Testosterone injections are the most common approach for TRT, but testosterone skin patches and creams are growing in popularity since they are practical and less invasive.
TRT entails the use of prescription testosterone, which comes in several different forms. The form of testosterone you use is relative to your preferences and lifestyle. The good news is that whether you prefer testosterone injections, gels/creams, or pellet implants, the results will be quite similar. You can read more about the different TRT treatment options below.
The most commonly prescribed and effective form of TRT is injectable testosterone. Unfortunately, injections are also one of the more invasive options.
Before you write off injectable testosterone, remember that it is safe, healthy, and effective when used correctly and under the guidance of a licensed physician specializing in androgen replacement therapy. Testosterone injections are also much more practical than you might presume.
In most cases, you will only need to inject once per week or every other week since the medication is an oil depot that gradually disperses the hormone to surrounding tissues. Testosterone injections, specifically testosterone cypionate and testosterone enanthate, provide smooth, stable plasma testosterone levels for 1-2 weeks, depending on the dosage.
A TRT dose of injectable testosterone usually ranges between 100-150 mg per week (or 200 mg every other week). Many men on TRT learn how to self-administer injections to do them at their convenience rather than make frequent visits to the clinic.
Becoming comfortable with injecting yourself is especially useful if you travel a lot or live further from your TRT prescriber's clinic. Don't worry, though. If you're not confident about giving yourself injections, you can always have a nurse at the doctor's office do it for you.
Testosterone gels and creams, such as AndroGel®, deliver testosterone transdermally (read: through the skin). Transdermal testosterone is the least invasive form of TRT and arguably the most convenient as well. Many men on TRT will opt for topical testosterone gels or creams if they have a needle phobia or are not comfortable having a testosterone pellet implant.
For optimal efficacy, shower immediately before applying a testosterone gel or cream and wait a few minutes after so it can completely dry on your skin before you put on clothing. (The most common area to apply gels/creams is the upper arms and shoulders.)
The main drawbacks of testosterone gels and creams are that they may give off an odor when rubbed on the body and that you have to let the substance actually "sink in" for proper absorption.
Unbeknownst to many users, testosterone gel/cream can transfer to another person's body if contact is made with the application site. Be careful to cover up the areas where you apply any testosterone gel or cream to avoid unwittingly exposing the hormone to others (especially children).
Testosterone patches, like the Androderm® patch, work similarly to testosterone gels and creams by delivering the hormone through the skin (albeit slower). It's recommended to apply the patch to the skin once daily in the hours leading up to bedtime. Doing so ensures that your testosterone levels will peak in the morning and slowly decrease throughout the day, mimicking the body's natural circadian rhythms.
One of the advantages of using a testosterone patch instead of a cream or gel is that you don't have to cover the application site, and it won't transfer to others who come in contact with the back of the patch. The medication (testosterone) is enclosed in the center of the patch and surrounded by an adhesive backing that sticks to your skin.
However, if you are someone with a lot of body hair or have oily skin, the patch might not adhere to the skin properly and may fall off, resulting in poor outcomes.
Testosterone pellets are the most researched form of testosterone replacement therapy and were the first method of treatment for male hypogonadism in the United States . The pellets themselves are about the size of a grain of rice and inserted into the hip area after a tiny incision is made (which is done in-office and relatively painless).
After the pellet is inserted, the body slowly metabolizes and absorbs the testosterone over the course of several months. A new pellet is needed roughly every six months to maintain stable testosterone replacement.
The main caveat of testosterone pellets is that health insurance companies rarely cover this form of testosterone therapy. In contrast, injections, gels/creams, and patches generally are covered (which can significantly reduce your medical expenses).
A testosterone pill is taken orally. For the most part, oral testosterone is a thing of the past for TRT purposes.
Taking testosterone orally means it must travel through the digestive tract, which subjects it to first-pass metabolism in the liver. Consequently, oral testosterone is less bioavailable than injections, implants, and transdermal options, as well as being much more stressful on the liver.
As much as 90% of oral testosterone metabolism occurs in the liver, and minute amounts of the original dose make it to the systemic circulation . Over time, the liver will continually produce high amounts of enzymes to metabolize oral testosterone, damaging hepatic cells and impairing liver function.
Therefore, using oral testosterone for treating androgen deficiency is risky in the long term and generally not as efficacious as the other options mentioned above.
The rise of testosterone therapy in men leads newcomers to believe it's the holy grail of anti-aging. Alas, that's not the most accurate expectation if you have low testosterone levels. Here's what you (realistically) should and should not expect if you decide to jump on testosterone replacement therapy.
TRT will not "restore" you to the level of physical fitness or sexual function of your teenage/early adult years, nor will it remedy all your symptoms overnight. If those are your expectations for testosterone therapy, you're in for a rude awakening.
However, there are ubiquitous benefits of TRT in the right circumstances. The majority of men on TRT are happy to say that, over time, it has helped them get back to feeling healthy, vigorous, and motivated. Those are the expectations you should have.
Hopefully, this guide to testosterone replacement therapy has given you useful insights into what causes low testosterone (male hypogonadism), how to diagnose it, and the potential benefits and risks of TRT. If your body is truly "shut down" and not producing enough testosterone naturally, then TRT may be a lifesaver (quite literally). Restoring your testosterone levels to a healthy range can increase libido, support healthy erectile function, boost energy levels, enhance bone density, improve muscle strength, bolster self-confidence, and promote cognitive function.
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