Up to five million men in the United States have low testosterone. Unfortunately, aging is a major risk factor for testosterone decline. After the age of 30, testosterone drops by about 1% per year. When testosterone levels fall below 300 nanograms per deciliter (ng/dl) in a man with symptoms consistent with low testosterone, this is referred to as male hypogonadism. The prevalence of hypogonadism increases with aging, obesity, diabetes, and other metabolic and age-related conditions. 

Restoring testosterone to normal physiologic levels is expected to:¹ 

• Increase lean body mass
• Increase upper body strength
• Decrease body fat
• Increase energy and motivation
• Improve mood, if related to low testosterone
• Increase libido

An estimated 4 to 5 million men in the United States have hypogonadism, with 60% of men over the age of sixty-five having free testosterone levels below the norm for men aged 30 to 35. Only 5% of men with low testosterone receive treatment.

Data suggests that healthy, older men commonly have minimal or no reduction in testosterone, whereas men with comorbid conditions such as diabetes experience the greatest declines.²

Over the last decade or two, U.S. testosterone prescriptions have tripled. More routine testing for erectile dysfunction seems to drive the increased prescribing practice. According to the American Urological Association, many men are using testosterone therapy without a clear medical indication. Another large group of men would clearly benefit from testosterone therapy and are not receiving it because of concerns about cardiovascular disease and prostate cancer. The American Urological Society’s position is that there is insufficient evidence to support these risks.³ 

What Are The Main Symptoms Of Low Testosterone?

Low testosterone does not always cause symptoms. When it does, you may experience the following sexual, neurological, and physical symptoms: 

Sexual: 

• Decreased sex drive or low libido
• Decreased fertility: reduced sperm count
• Erectile dysfunction: difficulty getting or maintaining an erection suitable for penetration
• Muscle loss: testosterone is an anabolic hormone that supports muscle and bone development
• Increased fat, especially abdominal fat
• Decreased testes size
• Decreased sexual hair

Neurologic/Psychiatric

• Mood changes: testosterone helps in regulating mood 
• Difficulty concentrating
• Decreased motivation
• Decreased self-confidence
• Decreased energy

Physical 

• Decreased energy levels
• Swollen or tender breasts; called gynecomastia
• Hot flushes
• Decreased physical strength
• Decreased muscle mass
• Increased body fat
• Anemia

What Are The Main Causes Of Low Testosterone? 

Testosterone is produced by the Leydig cells in the testes in response to an increase in luteinizing hormone by the pituitary gland. Therefore, decreased testosterone production is considered primary if it is due to a lack of production in the testes and secondary if it is due to a lack of luteinizing hormone.  

Causes of primary hypogonadism:⁴ 

• Chromosomal abnormalities
• Gene mutations
• Klinefelter’s syndrome
• Chemotherapy
• Low thyroid (hypothyroidism)
• Testicular injury or trauma

Causes of secondary hypogonadism:⁴

• Genetic conditions that affect the pituitary gland
• Chronic opioid use
• Increased prolactin hormone production
• Pituitary tumors
• Sleep deprivation
• Surgery or trauma to the pituitary

Medical conditions associated with decreased testosterone:⁵

• Obesity
• Diabetes
• Chronic obstructive pulmonary disease
• Chronic kidney disease
• Human immunodeficiency virus
• Opioid dependence

There are also lifestyle factors that can also negatively affect testosterone production, including: 

• Alcohol use⁶
• Steroid use
• Obesity
• Smoking

The most common reason for low testosterone is an age-related decline, especially when it is associated with other chronic diseases or lifestyle factors that increase the risk of these chronic diseases.  

Does Masturbation Lower Testosterone?

You may have heard the advice to refrain from sexual activity, whether partnered or not, before athletic events. The theory was that masturbation could lower testosterone levels, negatively impacting athletic performance. 

The scientific studies that support a link between masturbation and decreased testosterone levels are inconsistent. As you can imagine, it is difficult to standardize masturbation and study it in a research lab setting. 

To read more about these studies, read How Does Masturbation Affect Testosterone

How Do You Diagnose Low Testosterone? 

If you are experiencing symptoms consistent with low testosterone, the next step is to get your testosterone levels checked. Testing should be done in the morning, between 8 a.m. and 10 a.m., after an overnight fast, which is when testosterone levels are expected to be at their highest. To make a diagnosis, more than one sample should be obtained, and both samples should be collected in the morning hours.³ 

• Testosterone levels: At least two blood samples should be taken in the morning after fasting. Testosterone levels naturally fluctuate throughout the day.
• Sex hormone-binding globulin (SHBG): Testosterone circulates in the blood bound to sex hormone-binding globulin, bound to the protein albumin, or unbound. Only the free testosterone plus the testosterone bound to albumin is available to act on target tissues. Free testosterone and SHBG should be checked to determine the level of biologically active testosterone.
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH): LH and FSH are hormones secreted by the pituitary gland. LH stimulates the testes to produce testosterone, and FSH is involved in sperm production. Measuring these two hormone levels can help distinguish between low testosterone originating from a problem in the brain or pituitary gland from one in the testes.
• Prolactin: Prolactin is a pituitary hormone that stimulates milk production. Abnormal levels of prolactin can indicate a problem in the pituitary gland.
• Additional lab tests:
  • Hemoglobin level to check for red blood cell count. 
  • Lipid panel to check for cardiovascular risk. 
  • Prostate-specific antigen to screen for prostate cancer. 
  • A baseline level of free estrogen (AACC, 2020). When testosterone is supplemented, some of it will be converted to estrogen. A baseline level of highly sensitive estrogen will help determine how high the conversion rate is.

Clinicians use a total testosterone level below 300 ng/dL as a reasonable cut-off to support a diagnosis of low testosterone. A therapeutic or ‘normal’ testosterone range is defined as 450 -600 ng/dL.³

How Do You Treat Low Testosterone? 

Testosterone therapy comes in many forms. It is prescribed when a man has symptoms consistent with low testosterone and has testosterone or calculated free testosterone is in the borderline or low range.¹ 

Contraindications to starting testosterone therapy:⁴

• Breast cancer
• Increased red blood cell counts (polycythemia)
• Prostate cancer
• Elevated prostate-specific antigen
• Desire for fertility
• Severe lower urinary tract symptoms
• Uncontrolled congestive heart failure
• Untreated obstructive sleep apnea

Testosterone Enanthate

Testosterone enanthate is typically given for two to four weeks. It has a rapid onset of action and achieves adequate serum concentration without daily dosing. 

Disadvantages:

• Has higher than desired levels for 3 to 5 days
• Aggression
• Hypersexuality
• Increased red blood cells
• Rapid peaks and declines in testosterone levels
• Variable mood

Testosterone Undeconoate

Testosterone undecanoate is a longer-acting testosterone injection that uses short-acting testosterone as a loading dose. Because it is longer-acting, men can expect fewer injections, more stable testosterone levels, a more stable mood, and fewer red blood cell increases. 

Disadvantages:

• Requires a loading phase
• Increases the risk of an oil-based blood clot if the injection is made too quickly⁷

Testosterone undecanoate is only available through a Risk Evaluation and Mitigation Strategy (REMS) program and must be administered by a trained, registered care provider in an office or hospital setting due to the potential risk of an embolism.⁸ 

Testosterone Cypionate

Testosterone cypionate is a medium-acting testosterone that is used to treat low testosterone. The dosage can be adjusted based on age, sex, and diagnosis. 

Disadvantages:

• Typically administered as a deep muscular injection in the buttock
• Can increase cholesterol
• Increased risk for blood clots

Read More: Testosterone Cypionate: What is It? 

Testosterone Implants

Testosterone implants are small pellets containing medication that is implanted under the skin. Benefits include maintaining a more stable testosterone level, improving mood stability, and a lower risk of increased red blood cells. 

Disadvantages:

• Delayed onset
• Minor surgical procedure to implant the pellet
• Risk of infection
• Pellet extrusion from under the skin
• Symptom recurrence before the next pellet insertion 
• Difficult to adjust dosage

Testosterone Gel

Testosterone gel is simple to administer, is pain-free, and mimics a normal testosterone circadian rhythm. 

Disadvantages:

• Takes time for the gel to dry
• Risk of transferring testosterone to other people 
• Cannot be applied to the penis or scrotum
• Cannot be applied to irritated skin
• Can irritate the skin (up to one-third of men experience skin irritation)

Testosterone gels carry a black box warning that accidental transfer of testosterone gel to women or children can cause serious health problems. Bed linens and towels may also have testosterone gel on them and should be carefully handled and washed.⁸ 

Buccal Testosterone

 Buccal testosterone is a putty-like substance that is applied to the crevice between the upper lip and gum. The medication is absorbed across the mucosa of the mouth into the bloodstream. Buccal testosterone can only be applied to the upper gum, and it is important to alternate locations. 

Disadvantages:

• Easy to dislodge from the gum
• Can cause swollen or tender lips
• Can leave a bitter or unpleasant taste
• Can affect the taste of foods and drinks

Testosterone Patches

Testosterone patches share many of the benefits associated with testosterone gels but are easier to apply. 

Disadvantages:

• Should not be applied to oily or hairy skin
• Should not be applied over a bony prominence
• Need to choose a new application spot each night
• An application spot cannot be reused for a minimum of 7 days

Testosterone Nasal Gels

Testosterone nasal gels are applied to the inner lining of the nose, which makes them easier to apply and decreases the risk of transferring testosterone to women and children. 

Disadvantages: 

• May be difficult for some people to administer
• May cause headaches, coughs, sinus pain, or changes in smell and taste

Oral Testosterone

In March 2019, the U.S. Food and Drug Administration approved an oral pill form of testosterone undecanoate. However, FDA approval only extends to use for men with low testosterone secondary to a medical condition, not age-related low testosterone. 

The medication carries a black box warning that it may cause high blood pressure. The FDA states that the risk of high blood pressure outweighs any benefits received from treating age-related low testosterone. They also require that all testosterone products carry a warning label regarding the increased risk of strokes and heart attacks. 

Low testosterone levels are also associated with an increased incidence of cardiovascular disease and all-cause mortality. The relationship between low testosterone and chronic diseases, such as diabetes, is bidirectional.² Improving lifestyle factors that are associated with obesity, diabetes, and metabolic syndrome is expected to improve testosterone as well. 

When testosterone is prescribed to men with low-normal testosterone levels or without symptoms consistent with low testosterone, they are unlikely to experience improved sexual function, reduced cardiovascular disease risk, or improved mood. They may notice increased lean body mass and strength, similar to the results expected from using anabolic corticosteroids.¹

Read also: The Pros and Cons of Testosterone Therapy Methods

How Can I Increase My Testosterone Levels More Naturally? 

Lifestyle factors that may boost testosterone levels are also likely to improve overall health. Metabolic disease, obesity, and diabetes are chronic diseases that have been linked to decreased testosterone. Optimizing your overall health can help you naturally regulate your hormones.

Lifestyle changes that may boost your testosterone levels more naturally: 

• Choose whole foods that are healthy sources of fats
• Increase protein in your diet
• Make time for at least two strength-building exercise sessions each week
• Aim for 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity each week, or a combination of both.
• Quit smoking if you smoke
• Aim for 7 to 9 hours of restful sleep each night
• Boost your vitamin D by spending time outside 
• Use meditation or yoga to reduce stress
• Cut back on alcohol use
• Ask your doctor if any of your medications may be contributing to your symptoms or causing a decrease in testosterone as a side-effect
• Avoid endocrine disruptors

Learn more about How to Naturally Boost Your Testosterone

Do Foods Boost Testosterone? 

Testosterone is a hormone that your body produces. If your body does not get the nutrients it needs to produce testosterone, your levels may be lower. However, this would be unlikely unless you are on a very restrictive diet. With that said, there is research that supports foods that can boost testosterone levels. Most of these foods are rich in antioxidants and decrease inflammation. 

• Leafy greens
• Fatty fish
• Shellfish
• Ginger
• Onion
• Garlic
• Healthy sources of fats
• Eggs
• Cocoa products
• Berries

Read 8 Foods That May Help Boost Your Testosterone to learn more about the benefits these foods provide and the research that supports prioritizing them in your diet if you want to boost your testosterone levels more naturally. 

Summary

The normal aging process in men is associated with a progressive decline in both growth hormone and testosterone. Testosterone production is reduced by nearly one-third by age 70 and by one-half by age 80. Twenty percent of men aged 60 to 70 and more than half of men by age 80 meet the clinical definition of hypogonadism. Growth hormone starts to decrease in the third decade of life and declines by about 14% with each decade.⁹

Chronic illnesses such as high blood pressure, diabetes, obesity, metabolic syndrome, chronic kidney disease, and kidney failure are associated with decreased testosterone levels in men of all ages.¹⁰ 

Some men who have symptoms associated with low testosterone or who are concerned about the potential side effects associated with testosterone therapy may consider Sermorelin therapy instead. Sermorelin stimulates growth hormone production. Like testosterone, growth hormone declines with age. Restoring growth hormone levels is expected to decrease body fat, increase muscle mass, boost stamina and endurance, and improve sex drive. 

Start a treatment plan with Semorelin today!

DISCLAIMER

While we strive to always provide accurate, current, and safe advice in all of our articles and guides, it’s important to stress that they are no substitute for medical advice from a doctor or healthcare provider. You should always consult a practicing professional who can diagnose your specific case. The content we’ve included in this guide is merely meant to be informational and does not constitute medical advice. 

References:

1. Seal LJ. Male hypogonadism and testosterone replacement therapy. Medicine. 2013;41:557-561. 

2. Hackett G. An update on the role of testosterone replacement therapy in the management of hypogonadism. Ther Adv Urol. Apr 2016;8(2):147-60. doi:10.1177/1756287215617648

3. Mulhall JP TL, Brannigan RE et al. Evaluation and management of testosterone deficiency: AUA guideline. Urol. 2018;200(423)

4. Petering RC, Brooks NA. Testosterone Therapy: Review of Clinical Applications. Am Fam Physician. Oct 1 2017;96(7):441-449. 

5. Zarotsky V, Huang M-Y, Carman W, et al. Systematic Literature Review of the Epidemiology of Nongenetic Forms of Hypogonadism in Adult Males. Journal of Hormones. 2014/07/22 2014;2014:190347. doi:10.1155/2014/190347

6. Sarkola T, Eriksson CJP. Testosterone Increases in Men After a Low Dose of Alcohol. Alcoholism: Clinical and Experimental Research. 2003;27(4):682-685. doi:https://doi.org/10.1111/j.1530-0277.2003.tb04405.x

7. Access Data. Aveed™ (testosterone undecanoate) injection, for intramuscular use. 2014;

8. Thirumalai A, Berkseth KE, Amory JK. Treatment of Hypogonadism: Current and Future Therapies. F1000Res. 2017;6:68. doi:10.12688/f1000research.10102.1

9. Giannoulis MG, Martin FC, Nair KS, Umpleby AM, Sonksen P. Hormone Replacement Therapy and Physical Function in Healthy Older Men. Time to Talk Hormones? Endocrine Reviews. 2012;33(3):314-377. doi:10.1210/er.2012-1002

10. Reckelhoff JF, Yanes LL, Iliescu R, Fortepiani LA, Granger JP. Testosterone supplementation in aging men and women: possible impact on cardiovascular-renal disease. American Journal of Physiology-Renal Physiology. 2005/11/01 2005;289(5):F941-F948. doi:10.1152/ajprenal.00034.2005

Additional references:

Mayo Clinic. (2017). Testosterone Therapy: Mayo Clinic Radio [Video]. Retrieved from https://www.youtube.com/watch?v=BOtv4zIaN88
Miller, E. (2020). Testosterone Therapy. Drugwatch. https://www.drugwatch.com/testosterone/
Medline Plus. (2018). Testosterone Transdermal Patches. Retrieved from https://medlineplus.gov/druginfo/meds/a601118.html
Medline Plus. (2017). Testosterone Nasal Gel. Retrieved from https://medlineplus.gov/druginfo/meds/a615025.html
Medline Plus. (2018). Testosterone Topical. Retrieved from https://medlineplus.gov/druginfo/meds/a605020.html
Medline Plus. (2018). testosterone Buccal. Retrieved from https://medlineplus.gov/druginfo/meds/a603034.html
Medline Plus. (2019). Testosterone Injection. Retrieved from https://medlineplus.gov/druginfo/meds/a614041.html

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