Low Testosterone in Men: Real Deficiency Versus Marketing
Men's Health

Low Testosterone in Men: Real Deficiency Versus Marketing

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Testosterone has become a commercial product as much as a hormone. Clinics, supplements and online services promise energy, muscle and youth. Genuine deficiency exists, matters, and is treatable. It is also far less common than the marketing implies, and the tests are frequently done wrongly.

What testosterone does

It drives the development and maintenance of male reproductive tissue, sperm production, muscle mass and strength, bone density, red blood cell production, body hair, and contributes to libido, mood and energy.

Levels peak in early adulthood and decline gradually, by roughly 1 percent a year after about 30 to 40. That gradual decline is normal ageing, not a disease.

Symptoms of genuine deficiency

More specific:

  • Reduced libido
  • Erectile dysfunction, particularly loss of morning erections
  • Reduced spontaneous erections
  • Loss of body and facial hair
  • Small or shrinking testicles
  • Breast tissue enlargement, gynaecomastia
  • Infertility, low sperm count
  • Hot flushes
  • Loss of height, or fragility fracture from low bone density

Less specific, and shared with many other conditions:

  • Fatigue
  • Low mood, irritability
  • Poor concentration
  • Reduced muscle mass and strength
  • Increased body fat, especially abdominal
  • Poor sleep

The non-specific symptoms are the ones most used in advertising, and they are far more often caused by sleep apnoea, depression, thyroid disease, anaemia, diabetes, alcohol or simple overwork.

Causes

Primary, meaning testicular failure, with high LH and FSH:

  • Klinefelter syndrome
  • Undescended testes
  • Mumps orchitis
  • Testicular trauma, torsion or removal
  • Chemotherapy or radiotherapy

Secondary, meaning pituitary or hypothalamic, with low or normal LH and FSH:

  • Obesity, the most common contributor by a wide margin
  • Obstructive sleep apnoea
  • Type 2 diabetes and metabolic syndrome
  • Opioid use, a very common and under-recognised cause
  • Long-term glucocorticoids
  • Anabolic steroid use, past or present, which suppresses the axis and can do so permanently
  • Pituitary tumour, including prolactinoma
  • Haemochromatosis
  • Chronic illness, chronic kidney or liver disease, HIV
  • Severe stress, over-training and inadequate energy intake
  • Excess alcohol

Note how many of these are treatable at the cause. Addressing obesity, sleep apnoea and opioid use often restores testosterone without replacement.

Testing, done properly

This is where most errors occur.

  • Test total testosterone on a sample drawn in the morning, between 7 and 11 am, because levels are highest then and fall through the day
  • Test fasting, since food lowers the reading
  • Repeat on a second separate morning before accepting a low result. Single-sample diagnosis is not valid
  • Do not test during acute illness, after poor sleep, or during a flare of another condition
  • If total testosterone is borderline, measure SHBG and calculate free testosterone, since SHBG is raised by age, thyroid disease and liver disease and lowered by obesity, diabetes and steroids, which distorts the total
  • If low, measure LH, FSH and prolactin to distinguish primary from secondary, and consider pituitary imaging and iron studies where indicated
  • Baseline haematocrit, PSA in older men, and lipids before any treatment

Saliva testosterone tests and direct-care online panels frequently fail these conditions.

Treatment

First, treat the cause. Weight loss, treating sleep apnoea, reducing alcohol, reviewing opioids and glucocorticoids, improving glycaemic control, and adequate sleep and nutrition. In men with obesity-related secondary hypogonadism, this alone often restores levels.

Testosterone replacement is appropriate for men with consistently low levels on correct testing plus symptoms. Forms include gels, patches, injections and pellets.

Risks and considerations that are frequently glossed over:

  • It suppresses sperm production and can cause infertility, sometimes irreversibly. Men who want children should not take it; alternatives such as hCG or clomiphene exist and should be discussed
  • Raised haematocrit, increasing clot risk, requiring regular blood monitoring
  • Worsening of untreated sleep apnoea
  • Acne, oily skin, breast tenderness
  • Testicular shrinkage
  • Fluid retention
  • Gels transfer to partners and children by skin contact
  • Prostate monitoring is needed; it does not cause prostate cancer but can accelerate existing disease
  • Cardiovascular safety has been reassuring in recent large trials for men with genuine deficiency, but this does not extend to men with normal levels

Monitoring once started: testosterone level, haematocrit, PSA and symptoms at 3, 6 and 12 months, then annually.

What does not work

Over-the-counter testosterone boosters, tribulus, D-aspartic acid, most herbal blends and “male vitality” supplements have no credible evidence of raising testosterone meaningfully in men with normal levels. Some are contaminated with actual steroids, which is worse than useless.

What does raise testosterone naturally

Losing excess fat, resistance training, adequate sleep of seven to nine hours, treating sleep apnoea, reducing alcohol, managing stress, and correcting severe vitamin D or zinc deficiency where present. The effects are real but modest, and they are mostly the same things that improve health generally.

The honest summary

If you have specific symptoms such as loss of libido, loss of morning erections, shrinking testicles or infertility, get properly tested. If you have fatigue and low mood, get assessed for the much more likely causes first. Be sceptical of any service that tests once, in the afternoon, and prescribes immediately.

This is general information. Testosterone therapy has significant effects on fertility and requires monitoring, so it belongs with an endocrinologist or urologist rather than a direct-to-consumer clinic.