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Overcoming “Low T” Part 1: Testosterone Therapy

HappyCMAI had just finished training a client, when Phil (not his real name), my five o’clock first time appointment, came into the office and sat down in the chair opposite my desk.

Actually, it was more slumping than sitting. He looked somewhat like a tired ex-linebacker way past his prime, as opposed to a man on a mission to get fit.

“So, what brings you here today?” I asked.

“I, uh… my doctor told me I need to lose some weight,” he sheepishly replied.

“Do you think you need to lose some weight?” I asked.

“Yeah, I guess so. Things have kind of gotten out of hand the past few years.”

“Did your doctor give a specific reason why you need to lose weight or is it just for general health?”

“Well sort of. He said it might help with some of the other issues I’ve been having, besides my weight.”

This piqued my curiosity.

“Tell me about these other issues,” I said, leaning forward and making my best finger tent.

Phil went on to rhyme off a laundry list of symptoms that included low energy, depressed moods, loss of strength, poor sleep, lack of mental focus, night sweats and irritability.

“How’s your libido?” I asked.

“My what?” he replied.

“Your sex drive. How is it?”

“Oh yeah, I forgot about that. I don’t have one.”

I nodded my head reassuringly and said, “OK, no worries. We’ll come up with a plan to help get you back on track.”

Phil’s story is typical of many men who reach middle age and begin to feel the cumulative effects of a lifetime of less than optimal lifestyle choices. Any number of factors such as a bad diet, high stress, substance abuse or lack of exercise, combined with the natural aging process, can bring about a “tipping point” that results in the onset of a condition known as “Low T”.

Low T (also known as andropause) is the male equivalent of female menopause and is characterized by a decrease in the body’s production of the hormone testosterone, that can manifest itself in many of the vague but nevertheless distressing symptoms Phil was experiencing.

The natural decline of testosterone in men is estimated to be at a rate of 1% per year after the age of thirty or 10% per decade, with a concomitant rise in total body estrogen levels and a protein called sex hormone binding globulin (SHBG) that binds “free testosterone” making it unavailable for use by the body.

This can leave many once virile men looking and feeling like Richard Simmons on birth control pills by the time they reach their sixties. Not good for the manly mojo.


Unfortunately, because the hormonal decline seen in men suffering from Low T is less rapid and the symptoms not as pronounced as they are in menopausal women, there is still no general consensus in the medical community as to whether or not andropause is a valid condition that necessitates treatment.

The unwillingness of some physicians to treat or even acknowledge the existence of Low T, leaves many middle-aged men confused, depressed and more prone to act out behavioral patterns associated with the stereotypical midlife crisis: Getting divorced, buying a convertible sports car, hanging out at singles bars, leaving their shirt open two buttons too low and having sex with women nearly half their age (although technically this could be considered as medicinal).

But is it possible that the cringe worthy male midlife crisis might be prevented or at least partially averted by maintaining optimal testosterone levels?

Benefits of Testosterone

The Leydig cells in the testicles are responsible for producing approximately 95% of the testosterone in adult males, with the rest being produced by the adrenal glands.

Most men are familiar with the role that testosterone plays in their body when it comes to sex drive, deepening of the voice, body hair growth and muscle building. But few are aware of just how vital maintaining optimal testosterone levels is to their overall health.

There are receptors for testosterone located throughout your entire body and maintaining optimal testosterone levels well into adulthood has been shown to provide the following benefits:

•    Higher bone density to prevent osteopenia and osteoporosis.

•    Improved cardiovascular health to protect against heart disease and stroke.

•    Enhanced sex drive and improvement of erectile dysfunction.

•    Reduced body fat and increased muscle size and strength.

•    Improved mood, self-confidence, motivation and “drive”.

•    Better mental focus and concentration.

•    Improved blood sugar regulation, which may help to prevent diabetes.

•    Reduced risk of benign and/or cancerous prostate disease.

•    Increased energy levels and less chance of falling asleep on the couch while watching Dancing With The Stars with your wife.

With all of the seemingly miraculous benefits to be gained from maintaining optimal testosterone levels as you age, the question then becomes, “Just how is the average middle-aged guy supposed to do that?”

Testosterone Replacement Options

When choosing a testosterone replacement delivery method, there are a number factors that can influence your choices. These include cost, convenience, comfort with application (i.e. needles), insurance coverage, your daily schedule and your physician’s recommendation.

Intramuscular Injections

Intramuscular (IM) testosterone injections are one of the most commonly prescribed methods of delivery. They’re also the most inexpensive option for testosterone placement therapy and are usually covered by most insurance plans.

The two forms of IM injections most frequently used are Testosterone Cypionate and Testosterone Enanthate, which are generic medications. Dosages are given weekly or biweekly, and in cases of individuals who are “hyper-metabolizers “ (meaning they metabolize testosterone faster than normal), the dosage is divided into twice-weekly shots to maintain more stable blood levels and minimize conversion into estrogen.

Transdermal Patches

One of the less popular options used are transdermal patches such as the brands Testoderm and Androderm that are applied on the back or upper arms. The disadvantage of using transdermal patches is that they can sometimes cause irritation of the skin at the sight of application and the patch itself is susceptible to falling off when swimming or sweating during heavy exercise.

Sublingual Testosterone

Sublingual forms of testosterone replacement are delivered orally dissolving a tablet under your tongue or via time released tablet that is applied to your gum line above your front teeth. Sublingual forms of testosterone differ from old-school oral testosterone in that they are absorbed directly into the bloodstream, thereby passing the liver and avoiding any potential toxicity.

The disadvantages of this delivery method are the inconvenience of the dosing schedule (twice-daily application), concerns over transfer to partners through saliva (kissing) and the potential for gum irritation and inflammation.

Transdermal Gels and Creams

Transdermal gels and creams are becoming a popular option for men who are adverse to using needles and are seeking an easy application method that can be done at home. These gels or creams are typically applied once or twice daily to your stomach, shoulders and upper arms after showering.

The advantage of using gels and creams are more stable blood levels of testosterone because they are applied on a daily basis. The disadvantages are risk of transferring hormones to your partner or children via skin to skin contact and the inability to shower or swim for two hours after application due to the possibility of washing it off.

The two most popular brands of gel on the market currently are Androgel and Testim which come in 5 g packets (containing 1% testosterone). Unfortunately these brand names can be quite expensive if paying out of pocket, however they are usually covered by most insurance plans.


Compounded creams and gels are a more economical option for individuals without an insurance plan. These formulations are mixed by a compounding pharmacist trained in making customize prescription formulations. The advantage of these compounded medications is that they can contain higher testosterone concentrations (typically 2 to 10% testosterone) for men who require more testosterone to get their blood levels up to optimum.

The disadvantage of compounded gels and creams is the concern over product consistency, which can differ from pharmacy to pharmacy and also there have been concerns expressed by some physicians that higher concentrations of testosterone tend to convert more into dihydrotestosterone (DHT). Higher levels of DHT may contribute to prostate enlargement, acne and premature balding in some men.

Testosterone Pellets

Pellets are made up of a compressed testosterone medication that are about the size of a grain of rice. The pellets are surgically implanted underneath the skin in the upper buttocks and this has the effect of slowly releasing the testosterone into your system over a three to four month time period.

This method of delivery can be advantageous to men who are adverse to needles, travel a lot or simply tend to be forgetful when it comes to maintaining a daily testosterone dosing schedule. The disadvantages of testosterone pellets are the risk of infection from surgery, difficulties in determining the correct dosage and there is the slight chance the pellets can work their way out through the skin.

The Good, the Bad and the Ugly

If you pay any attention at all to the mainstream media, you’ve no doubt seen the reports on legions of male baby boomers rushing to their doctor’s office asking to be put on Testosterone Replacement Therapy (TRT).

Many men have reported that TRT has significantly improved their quality of life, helping them to regain their edge in both the boardroom and the bedroom. However, if you are considering going on TRT, then it’s essential that you do your homework and find a physician skilled in treating andropause with the appropriate lab testing, interpretation of symptoms and correct prescribing of hormones.

You should be aware that testosterone does not work alone in the body and must be balanced with other hormones such as DHEA, thyroid, insulin, cortisol, estrogen and others.

Even though TRT can be a boon for men suffering with Low T, it’s not a panacea nor is it something to be taken lightly. Failure to properly measure, monitor and balance all of the hormones can lead to the following side effects:


It’s a bit of a tongue twister, but it’s simply the technical term for increased red blood cell production. Why does this matter? Improper administration of TRT can cause your blood to become too viscous or thick, which increases your risk for a heart attack or a stroke.

However, periodic monitoring of hematocrit and/or hemoglobin by your physician and then donating blood if an unhealthy elevation is detected, can help to effectively manage this situation.

Testicular Atrophy

TRT can cause the hypothalamus in your brain to shut down production of gonadotropin releasing hormone (GnRH), which in turn stops the pituitary from releasing luteinizing hormone (LH). Without the production of LH, your testicles will cease output of what little testosterone they may have still been producing on their own.

This results in a reduction of the size and firmness of the testicles – in other words, your giblets can shrink. Some men don’t mind this side effect, but those that do can speak to their physician about injections of human chorionic gonadotropin (hCG) hormone to help prevent and even reverse it.


This is a condition that is jokingly referred to as “bitch tits” by Crazee Wear clad bodybuilders who use large doses of anabolic steroids. Although gynecomastia is rare in men given physiological doses of TRT, there are some individuals that have a propensity for converting testosterone into excess estrogen due to an enzyme called aromatase. This can cause a benign growth of glandular tissue in males, resulting in unsightly breast enlargement.

If you fall into this category, then you can speak to your physician about taking an aromatase inhibiting medication to help minimize this occurrence. Interestingly enough, low testosterone levels can also cause gynecomastia.


Another unfortunate side effect of TRT (depending on your perspective) is that it could significantly reduce your sperm count – often times to zero. If you’re not planning on siring the next Brady Bunch, then this will be of little consequence to you.

But if you choose to go on TRT and still want kids, then there is a way to have your birthday cake and eat it too. Talk to your doctor about injections of human chorionic gonadotropin (hCG) hormone to help keep your sperm swimming swiftly along.

Prostate Cancer

For the past several decades, most medical students have been taught that giving TRT to older men increases their risk for prostate cancer. If prostate cancer was already present, then it was considered to be the equivalent of “throwing gasoline on a fire.”

However, It turns out – based upon the most current research conducted by Abraham Morgentaler M.D. and his colleagues at Harvard Medical School – that high testosterone levels do not increase the risk of prostate cancer and in fact, low testosterone levels may actually increase the risk.

In his book Testosterone for Life, Dr. Morgentaler states:

“The relationship of testosterone to prostate cancer has undergone a significant reevaluation, and all recent evidence has reinforced that T therapy is safe for the prostate.”

These new revelations may explain why young men with the highest testosterone levels have the lowest incidence of prostate cancer, compared to older men who have lower testosterone levels and higher prostate cancer rates.

Of course, if you’ve recently been diagnosed with prostate cancer or you have been treated for it in the past, then it would be prudent to thoroughly discuss all of your options with your physician.


As you can see, overcoming Low T is not as simple as just getting weekly testosterone injections or rubbing a gel onto your skin. Without proper due diligence, your quest to go from a cubicle dwelling Clark Kent to a high flying Superman could end up leaving you permanently grounded.

In Part 2 of this series I will be discussing the ideal carbohydrate food choices for managing Low T by balancing blood sugar and hormones, as well as maximizing energy production.

Do you agree or disagree with this article? Share your thoughts in the comment box below!

Alvin M Matsumoto, MD. Fundamental Aspects of Hypogonadism in the Aging Male. Review in Urology 2003; v.5(Suppl 1).

Nazem Bassil, Saad Alkaade, John E Morley. The Benefits and Risks of Testosterone Replacement Therapy: A Review. Therapeutics in Clinical Risk Management 2009; v.5; PMC2701485.

Prasanth N. Surampudi, Christina Wang, Ronald Swerdloff. Hypogonadism in the Aging Male Diagnosis, Potential Benefits, and Risks of Testosterone Replacement Therapy. International Journal of Endocrinology; v.2012; PMC3312212.

Hsieh TC, Pastuszak AW, Hwang K, Lipshultz LI. Concomitant Intramuscular Human Chorionic Gonadotropin Preserves Spermatogenesis in Men Undergoing Testosterone Replacement Therapy. Journal of Urology 2012; pii: S0022-5347(12)04867-7.

Vergel N. Testosterone: A Man’s Guide. Practical tips for boosting physical, mental and sexual vitality. Milestones Publishing 2011.

Agarwal PK, Oefelein MG. Testosterone Replacement Therapy After Primary Treatment for Prostate Cancer. The Journal of Urology 2005; 173(2):533-6.

Hermann M. Behre, Sabine Kliesch, Eckhard Leifke,Thomas M. Link, Eberhard Nieschlag. Long-Term Effect of Testosterone Therapy on Bone Mineral Density in Hypogonadal Men. The Journal of Clinical Endocrinology & Metabolism 1997; Behre et al. 82 (8): 2386.

John P Mulhall, MD. Treatment of Erectile Dysfunction in a Hypogonadal Male. Reviews in Urology 2004; v.6(Suppl 6); PMC1472882.




Disclaimer: The information contained on this website is for educational purposes only. It is not intended to diagnose, treat or cure any disease. Persons with any health-related issues should consult a qualified healthcare provider.


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