Understanding Low Testosterone
Testosterone deficiency (hypogonadism) affects an estimated 20-40% of men over age 45. Symptoms are often gradual and attributed to "normal aging," but they significantly impact quality of life:
- Fatigue and low energy
- Decreased libido and erectile dysfunction
- Loss of muscle mass and increased body fat
- Depression, irritability, and brain fog
- Poor sleep quality
- Decreased bone density
Diagnosis
Proper diagnosis requires both symptoms AND confirmed low testosterone levels on blood testing. Key labs include:
Essential: Total Testosterone, Free Testosterone, SHBG, Estradiol (sensitive), LH, FSH, CBC (hematocrit), Comprehensive Metabolic Panel
Additional: Prolactin, Thyroid panel (TSH, Free T3, Free T4), PSA, Lipid panel, DHEA-S, IGF-1
Testing should be done fasting, in the morning (before 10 AM), as testosterone levels follow a circadian rhythm with peak levels in the early morning.
TRT Protocol Options
Testosterone Cypionate/Enanthate Injections
The most common and cost-effective approach. Typical starting dose is 100-120 mg/week, split into 2 injections (e.g., 50-60 mg every 3.5 days) for more stable blood levels.
Advantages: Precise dosing, cost-effective, well-studied Considerations: Requires injections, some men dislike needles
Testosterone Cream/Gel
Applied daily to the skin (typically shoulders, inner thighs, or scrotum). Scrotal application produces higher DHT levels.
Advantages: No injections, daily application mimics natural rhythm Considerations: Transfer risk to partners/children, variable absorption, more expensive
Testosterone Pellets
Implanted subcutaneously every 3-6 months. Provides steady-state levels.
Advantages: Convenience, steady levels Considerations: Minor surgical procedure, difficult to adjust dose, potential extrusion
Ancillary Medications
HCG (Human Chorionic Gonadotropin)
Maintains testicular size, fertility, and intratesticular hormone production. Typical dose: 250-500 IU, 2-3 times per week.
Anastrozole
Aromatase inhibitor used to manage estradiol levels if they rise too high. Used judiciously — the goal is optimal estradiol, not suppressed estradiol. Typical dose: 0.25-0.5 mg, 1-3 times per week as needed.
Enclomiphene
Can be used as a TRT alternative (stimulates endogenous production) or alongside TRT to maintain some HPG axis function.
Monitoring
Regular bloodwork is essential. Check labs at 6-8 weeks after starting or adjusting dose, then every 3-6 months once stable:
- Total and Free Testosterone (target: 700-1100 ng/dL total)
- Estradiol sensitive (target: 20-35 pg/mL)
- Hematocrit (watch for >54%)
- PSA (prostate screening)
- Lipid panel
- Comprehensive metabolic panel
Common Mistakes
- Starting dose too high — Start conservative and titrate up based on labs and symptoms
- Infrequent injections — Once-weekly or biweekly injections cause hormone rollercoasters; split into 2+ doses per week
- Over-using aromatase inhibitors — Crashed estradiol feels worse than high estradiol
- Ignoring hematocrit — Donate blood if hematocrit rises above 52-54%
- Not addressing root causes — Sleep, stress, diet, and exercise all affect testosterone; TRT works best as part of a comprehensive approach
Lifestyle Optimization
TRT works synergistically with lifestyle factors:
- Sleep: 7-9 hours of quality sleep
- Exercise: Resistance training 3-4x/week, moderate cardio
- Nutrition: Adequate protein, healthy fats, micronutrient sufficiency
- Stress management: Chronic stress elevates cortisol, which antagonizes testosterone
- Body composition: Excess body fat increases aromatization