Note – This is the first of a four-part series. Click here for Part 2 on symptoms, here for Part 3 regarding my TRT results, and here for Part 4 on finding treatment.
Over the past two years, researching testosterone and testosterone replacement therapy (TRT) has played a very important role in the trajectory of my life.
After what seemed like a lifetime of beating my head against the wall dealing with various symptoms, I finally decided to get my hormone levels checked in the spring of 2014.
The results came back showing a level that my doctor could only interpret as a mistake.
A follow-up draw confirmed there was no mistake in the testing procedures – just woefully low testosterone levels.
I was 28 years old and for the first time, I felt like I had a solution to the problems that had been plaguing me for years.
In this and articles to follow, I want to share my low T journey and experience with TRT.
But before I get into my own experience, I need to give you a brief overview of what I’ve learned about low testosterone, the diagnostic process, and treatment.
What does testosterone do for you?
Stated simply, it makes you a man.
It’s responsible for everything that makes you strong, healthy, and powerful. As a man, without testosterone, you’ll be mentally, physically, and emotionally frail (I know this first hand).
Optimal levels of testosterone are associated with:
- Low body fat
- High muscle mass
- Optimal bone density
- Low levels of depression
- Mental and emotional resilience
- Abundant energy
- Greater sense of well-being
- Clear mind
- Healthy sex drive and sexual function
- Decreased risk of heart disease
Basically, every aspect of life is better with optimal levels of testosterone.
Symptoms of low testosterone
Men suffering from low testosterone (hypogonadism) frequently exhibit a selection of the symptoms below, and more often than not, they experience a large number of them.
- Low muscle mass
- High body fat
- Brain fog
- Low libido
- Erectile dysfunction
- Mood swings
- Low bone density
- Heart disease
- Low self-confidence
In short, life with low testosterone is miserable.
Note – To get your testosterone levels checked, call the company I use, Primebody.com and get a free consultation, $25 off your monthly fee, and an additional 10% off your first month and when you use the code Lewis27.
Causes of low testosterone
There has been a rapid decline in testosterone levels spanning recent decades.
Men today have lower levels than previous generations did at the same age. And there are many theories to explain this.
The common suspected causes include inactive lifestyles, exposure to chemicals found in plastics, lack of quality food, and unhealthy levels of stress, to name a few.
Steroid abuse and the use of certain medications, like painkillers and antipsychotics, can also suppress testosterone levels.
However, since this decline is seen across the board in every age bracket and geographic location, I think it’s safe to say that a combination of all these factors is to blame.
Modern men simply are not living high testosterone lifestyles.
It’s important to note that when multiple lifestyle factors are improved all at once, testosterone levels often rise.
Not to the same levels as supplementing with synthetic testosterone, but they rise nonetheless.
This supports the notion that testosterone levels are a good indicator of overall health and can be corrected through lifestyle intervention in some cases.
If, for example, you go from being completely sedentary and eating nothing except junk food to an active lifestyle with a diet consisting of high quality whole foods, you can accomplish much of the same thing, minus the injections.
So resist the temptation to jump straight to hormone therapy.
The ABCs of TRT
First, while I'll do my best to not overuse abbreviations, here's a cheat sheet for you to easily refer back to if you need a quick reminder.
Don't feel compelled to memorize the chart, but it's here if you need it.
|AI||Aromatase Inhibitor||A medication that binds to the enzyme responsible for converting testosterone to estradiol.|
|E2||Estradiol||The form of estrogen that results from aromatization of testosterone.|
|FSH||Follicle-Stimulating Hormone||Released by the pituitary gland. Stimulates sperm production.|
|FT||Free Testosterone||Unbound portion of testosterone.|
|GnRH||Gonadotropin-Releasing Hormone||Released by the hypothalamus. Signals the pituitary gland to release LH and FSH.|
|hCG||Human Chorionic Gonadotropin||A medication that mimics LH, thus signals the testes to produce testosterone.|
|LH||Luteinizing Hormone||Released by the pituitary gland. Stimulates testosterone production.|
|SHBG||Sex Hormone Binding Globulin||Binds to sex hormones, making them biologically inactive.|
|TRT||Testosterone Replacement Therapy||Replacing natural testosterone with synthetic.|
|TT||Total Testosterone||Total testosterone found in the body.|
How testosterone is made
Don’t worry – I’m not going to give you an in-depth physiology lesson here, but a brief understanding of how testosterone is produced in the body will help the rest of this series make more sense.
When interpreting a hormone screen, doctors will most often focus on a few key values:
Total Testosterone (TT)
This is the total amount of testosterone in your blood, measured in nanograms per deciliter (ng/dL). It’s also the most commonly discussed number and the one most frequently used to determine the need for trt.
Free testosterone (FT)
This is the amount of testosterone in your blood that isn't bound by Sex Hormone Binding Globulin (SHBG) and is free to act on tissues, giving you masculine characteristics. Free testosterone is measured in picograms per milliliter (pg/mL).
FT is actually more important in diagnosing low T than total test, but is often overlooked by medical professionals.
I had to specifically request that my previous doctor test for this value. And it's never a good sign when the patient has to guide the diagnostic process.
It's actually possible to have normal to high total testosterone, but have low free testosterone. In this case, men often have all of the symptoms associated with low total testosterone, despite normal looking lab results.
This value refers to your estrogen levels. Even though estrogen is the female sex hormone, some is still required in the male body.
It's not a terribly important value in the diagnostic process, but it's extremely important to monitor should you decide to undergo treatment.
Estradiol levels can give insight into many of the common side effects of TRT.
Reference range of “healthy” testosterone levels
A reference range is simply the set of values to which your blood test results get compared.
For testosterone levels, most doctors and labs will often use a reference range close to 300 – 1,200 ng/dl.
Labcorp, where I now get my blood tested, uses a reference range of 348 – 1,197.
For many doctors, if your TT falls anywhere within the reference range (or even a little below), they will consider you to be healthy and will not advise you to pursue TRT.
Problems with the reference range
The problem with this range is that it’s a compilation of test results and is much too broad. It includes men ages 18 to 80 living all types of lifestyles.
On the surface, using a compilation of test results sounds reasonable.
But who do you think is going in to have their hormone levels checked?
In many cases, it’s going to be men suffering from low testosterone symptoms, those with unexplained health conditions, and men having issues with infertility.
Healthy patients rarely go in for hormone screenings and doctors don't have any reason to order them.
So to create this reference range, they are actually including test results from men with low testosterone levels to determine what a normal testosterone level is.
You can see why this may be problematic.
According to the current range, a healthy, active 25-year old male with the same testosterone levels as a sedentary, 85-year old man is perfectly “normal” and will not qualify for treatment.
To further illustrate the issue, let’s compare the measurement of testosterone levels to blood pressure ranges.
In regard to blood pressure, an optimal reading will be under 120/80 mm Hg.
If, however, we included individuals with hypertension into the sample pool and used their values to formulate a “normal” range, the situation would be entirely different.
In that scenario, we would have doctors telling their patients that a blood pressure reading of 160/110 mm Hg (stage 2 hypertension) is perfectly fine and it’s just a normal part of aging.
When we look at testosterone levels adjusted for age, we find out that a young man near the bottom of the current reference range is very much below average.
Testosterone levels adjusted for age
(1) Average Testosterone Levels by Age in Men
(2) Normal Testosterone Levels in Men (Non-diabetic)
Source for charts: Androgens and the Aging Male
(1) Vermeulen A. Declining androgens with age – an overview, In: Androgens and the ageing male. Eds. Oddens B. Vermeulen A. Parthenon Publishing. New York. 1996
(2) Simon D. Nahoul K. Chades MA. Sex hormones, ageing, ethnicity and insulin sensitivity in men : an overview of the Telecom study. In: Androgens and the ageing male. Eds. Oddens B. Vermeulen A. Parthenon Publishing. New York. 1996
What were my testosterone levels?
As you can see, my first blood work revealed that I had a total testosterone level of 289 ng/dL.
I was extremely low, even when compared to a reference range that includes men with low testosterone!
This was low enough for my doctor to presume a mistake had been made even though blood was drawn under ideal conditions (which are after fasting for 12 hours and having the draw performed within 2 hours of waking).
My follow-up blood work was performed about a week later and came back at 287 ng/dL.
I was then referred to a urologist who ordered another blood draw. Those results came in at 292 ng/dL.
At least I was consistent…
And while I forget the reason, he had me do yet another blood draw which showed my total test at 225 ng/dL.
This was drawn about 3 or 4 hours after waking up, which explains why it was lower than the previous three. Testosterone levels are naturally highest in the morning and decline throughout the day, so that showed normal fluctuations.
I don't know what my baseline free testosterone levels were as my doctors didn't check them initially.
The first time I had it checked in July 2014, my total T had been raised up to 451 ng/dL through the use of hCG, but my free T wasn't even up to the bottom of the range yet. Yikes!
How do I stack up against my age group?
Excluding the outlier of 225 ng/dL, my average was 289 ng/dL at 28 years old.
According to the studies that actually included healthy males and have grouped results by age, well, I wasn't even close to being on the chart.
The bottom 5% of my age group (25 to 29 year olds) have a TT level of 388 ng/dL. The average TT for 354 subjects was 669 ng/dL.
My test levels were actually significantly lower than the 85 to 100 year old age group, who had an average TT level of 376 ng/dL.
No wonder I looked and felt like an old man!
Words can hardly express what a relief it was to find out the source of my problems. I didn't want to have low testosterone, of course, but at least now I had a course of action in sight.
So you find out you have low T, get a prescription for testosterone from your doctor, and start your treatment, right?
While synthetic testosterone as a standalone works just fine for some, most men find that they need a couple other medications to function optimally.
The body is an extremely complex organism and the manipulation of one hormone often causes others get out of balance.
When testosterone levels increase, the body will convert some of the excess to estrogen through a process know as aromatization. This process can result in some unwanted side effects (i.e., gynecomastia and water retention).
To prevent estrogenic side effects, an aromatase inhibitor (AI) will keep E2 levels in check and is a frequently prescribed and useful addition to TRT.
Another common side effect of introducing exogenous (from the outside) testosterone is testicular atrophy (aka, shrunken balls).
Since your body doesn’t need to make its own testosterone when supplementing, your pituitary gland will decrease its release of LH (see the diagram for a refresher).
When the testes aren’t receiving the the signal to produce T, they shut down or atrophy.
Human Chorionic Gonadotropin (hCG) is a medication that mimics LH and will keep your testes functioning.
This will help for cosmetic reasons (fight shrinkage!), maintaining fertility, and to preserve natural testosterone production in the event that one ever decides to cease treatment.
The use of testosterone, an AI, and hCG is widely recognized as the holy trinity of life-long, successful TRT.
The problem with the current state of treatment
Despite the increasing prevalence of low T across all age groups, many low T sufferers are still facing barriers to receiving optimal treatment, or even treatment at all.
Though the TRT industry is growing, doctors aren't all on the same page yet about what treatments and dosages are appropriate or whether TRT is pertinent at all.
Why are most doctors hesitant to provide adequate treatment?
After talking with several doctors, reading dozens of first-hand accounts, and listening to many horror stories, I've recognized a few patterns with the way certain medical professionals view TRT and why many men aren't receiving adequate treatment.
1. They’re undereducated in this particular field
Since testosterone replacement therapy is relatively new, in popularity at least, many doctors are still hesitant to provide treatment in the interest of protecting themselves.
TRT isn’t a major component of medical school, so doctors either have to specialize or simply rely on reference ranges and general guidelines (and we now know those are faulty).
There isn’t a whole lot of history in treating low T and if you spend any time on forums with guys discussing their treatment, you’ll see that methods and dosing have evolved drastically even since 2010.
Compare that to treating high cholesterol or depression and it's clear that TRT is basically in its infancy.
As recently as just a few years ago, doctors were giving large dose injections once per month and doing more harm than good (some are still doing this).
There is a very successful formula for treating low testosterone that's taking shape, but it just isn’t widely available.
Some doctors aren't willing to dig for information and to go outside of common procedures in the interest of treating a problem they view as insignificant.
2. Public perception of testosterone is negative
Society views anything associated with testosterone to be violent and in-your-face.
Just mentioning the word “testosterone” causes most people to conjure up images of anger and aggression – hairy, sweaty men swilling cheap beer, catcalling, and revving their motorcycles to scare the neighborhood children.
Doctors aren’t in a hurry to jump on board and have their practices associated with this image.
In addition, the patients themselves may not bother seeking treatment when spouses, family, or friends hold a negative opinion of the effects of testosterone.
3. Using testosterone is viewed as cheating
The media likes to highlight TRT in professional sports and lump it together with steroid use. And steroids are cheating (so we've been told).
Doctors instantly assume that a young guy complaining of low T symptoms is just fishing for a safe/legal steroid prescription.
They fail to take into account that athletes aren’t taking the same therapeutic, low-dose treatment as someone on TRT.
Not to mention the fact that the patient could have a desperate need for treatment and he's being discounted because of the doctor's own bias.
I’m not against steroid use or taking high doses of testosterone (I'm open to trying both at a later point in my life).
I’m simply pointing out that there’s a difference between using a small, therapeutic dose under the care of a medical professional to overcome a deficiency and taking large amounts of testosterone to drastically improve athletic performance.
Who should be on TRT?
Testosterone replacement therapy is presently viewed as an older man’s game.
You see the commercials featuring 50-year old men rebuilding an engine and dancing with their wives in the kitchen.
Basically, everything written talks about how testosterone levels start to decline after a certain age.
Whether or not the decline is a natural part of aging or the consequence of the average middle-aged man's lifestyle, there are absolutely older men who can benefit from TRT.
But what if you’re under 30 and having symptoms?
Low testosterone isn’t necessarily the result of a natural decline.
There are plenty of guys (like myself) who never reached optimal levels in the first place.
I’ve spent the last two years reading comments on blogs and discussions on various forums and have noticed that there’s an overwhelming number of young men under 30 experiencing severe low T symptoms.
Note – If you're having symptoms and want get your levels checked, call the company I use, Primebody.com and get a free consultation, $25 off your monthly fee, and an additional 10% off your first month and when you use the code Lewis27.
I get emails and comments from guys who are dealing with all of these negatives and are in their 20s!
Regardless of age, from my experience, anyone with a need should seek getting better.
My first recommendation though is to examine and correct any glaring lifestyle issues. Consider whether these areas of your life are generally healthy and in balance:
- Stress and rest
- Substance abuse problems
If not, work on these areas first and see if you experience a significant reduction of your low T symptoms.
For some though, even hitting these high T lifestyle factors isn’t enough.
For men with hypogonadism, taking natural testosterone boosters and adopting a Paleo diet just isn’t going to cut it.
That’s why I’m here to share my experience with you.
In the following installments in this testosterone series, you’ll get my perspective as a young man under 30 who’s suffered from a lifetime of low-T and is now getting treatment.
More to come,
Note – This is the first of a four-part series. Click here for Part 2 on symptoms, here for Part 3 regarding my TRT results, and here for Part 4 on finding treatment.