“Middle age,” according to several dictionaries and the American Psychiatric Association, begins at roughly 45 and runs all the way to 65. But for me, it actually came early—at 38. Until then, I’d always been an active guy—not a star athlete, to be sure, but someone who did calisthenics every morning, walked to work, and ran about 10 miles a week. I ate a balanced diet and was naturally slim. But then, last year, I inexplicably started gaining weight and feeling exhausted most of the time; mysterious, often-debilitating aches and pains began shooting through my muscles and joints. For much of the past 12 months I couldn’t even walk without the aid of crutches or an orthopedic boot, having developed an excruciating case of tendinitis in both feet simultaneously. It felt as if the bottom had fallen out of my life—like age had finally caught up to me and run me over. I fell into a depression.
To fight back, I sought out Michael Matthews’ 2014 book, Bigger Leaner Stronger: The Simple Science of Building the Ultimate Male Body—an Amazon top seller—and read it with highlighter in hand. Following Matthews’ program, I switched to a high-protein diet of “clean” foods—lean meats, Greek yogurt, fruits, green vegetables—and made sure I got eight hours of sleep a night. I even lightened my schedule to reduce stress.
In the gym, I became an early-morning regular, doing heavy compound lifts three days a week. I lost some fat, sure, but made only negligible gains in muscle mass. If anything, all that pumping iron caused my body to hurt only more. Nothing I did seemed to work; I didn’t feel any better. In fact, I felt only more exhausted, particularly at night, which, let’s just say, isn’t exactly great for a marriage. That was the final straw.
Frustrated and confused, I scheduled an appointment with my primary care doctor for a blood test. Reviewing the results, he did a double take: “This can’t be right,” he said—never something you want to hear from a doctor. “Your testosterone is superlow.”
He referred me to an endocrinologist, and two more blood tests confirmed it: My blood testosterone level was just 133 nanograms per deciliter (ng/dl), well below the generally agreed-upon “normal” range of roughly 270 to 1,070. To put that into perspective, even the average male octogenarian in a nursing home scores in the upper 300s.
As his words sunk in, all I could think about were those ubiquitous low-T ads on TV—the ones featuring handsome middle-aged men astride motorcycles in the desert, staring longingly into the distance, while voice-overs promising a new T therapy as a fountain of youth play on loop. Like just about every guy, I’d made fun of those commercials for years. I wasn’t that grizzled old dude already... was I?
Like it or not, I was about to find out. The endocrinologist couldn’t say for sure whether all my symptoms were the fault of testosterone deficiency, but he nevertheless recommended testosterone treatment, and I agreed.
The "Magical" world of low T
The importance of testosterone to male health has been understood since at least the 1930s. A steroid hormone produced in the testicles, T encourages the expression of male sexual characteristics like big muscles, body hair, an Adam’s apple, and a deep voice. It also boosts self-confidence, focus, motivation, aggression, and—perhaps most important to many men who don’t have enough of it—libido and the ability to get an erection.
As males, most of us reach peak T by age 20, after which our levels tend to remain steady. After age 30, however, testosterone begins to decline by up to 1% per year. Scientists don’t know why, but as we grow older, T begins to recede like an outgoing tide. And as it falls, men experience a cascade of negative effects: depression, hot flashes and sweats, exhaustion, forgetfulness. Declining T also means declining muscle mass and bone density, and, of course, trouble getting it up.
Which is why, more and more in this day and age, the push for—and ready availability of—testosterone-replacement therapy, or TRT, has become an issue.
Never before in the history of medicine has testosterone been so abundant and readily available, from physicians as well as any number of low-T clinics that have sprung up across the country and online. The business of T is booming. Those low-T ads I mentioned? In 2012 alone, T-related advertising skyrocketed from $14.3 to $107.3 billion. By 2013, the FDA reported that 2.3 million American men had received prescriptions for supplemental testosterone. Only a year later, that number nearly tripled to 6.5 million, according to IMS Health, a health-care research firm. The total value of the global TRT market already stands in excess of $2 billion but is anticipated to reach $6.5 billion by 2020, according to a recent report by Global Industry Analysts.
TRT can take many forms, depending on the prescribing doctor: injections, adhesive patches, nasal sprays, oral ointments, subcutaneous pellets, and even suppositories, all of which have their pros and cons. But by far the most popular form of TRT prescribed both by low-T clinics and doctors is AndroGel, a clear gel you rub on your shoulders and upper arms once a day, every day, for as long as you want, even forever if you so choose.
Sorry, super-shredded fellas, but that’s the baseline percentage of body fat you need if you want to maximize your baseline testosterone, according to Bradley Anawalt, M.D. If your body fat dips below 10%, it creates “the canary in the coal mine” effect, he says. In other words: Your body senses an imminent death. “The brain thinks you’re starving, so instead of vamping up reproductive function, it turns it down. T is the first of the hormones to fall out.”
The trouble with TRT
Once you’ve started on T therapy, the results don’t take long to appear.
After only a week or two of TRT, many patients, even those of advanced age, experience a significant increase in libido as well as a sunnier mood and a general sense of well-being, says Ronald Swerdloff, M.D., chief of the division of endocrinology and metabolism at Harbor-UCLA Medical Center. Of course, not everything happens so fast—other benefits, including improved strength and bone density, may take six to 12 months to manifest.
But—and it’s a big but—along with the benefits of TRT come health risks as well. Physicians caution that taking T could hasten the growth of preexisting cancerous cells. Other documented side effects include, ironically, testicular shrinkage and infertility. TRT can also be dangerous for men with sleep apnea, worsening its symptoms.
But by far the biggest concern is that taking T may increase red blood cells, which could lead to heart attack or stroke. For decades, drug companies pushed estrogen pills as an anti-aging elixir for menopausal women until, in 2002, a federal study found that estrogen therapy placed patients at significantly greater risk of breast cancer, heart attack, and stroke. As of yet, no such far-reaching clinical studies have been performed on TRT, leaving many questions about its safety and efficacy unanswered.
Less serious, but still a concern, is the fact that TRT temporarily stops your body from producing T naturally. The fact is, no matter how TRT is delivered, it doesn’t cure low testosterone—it simply supplies a hormone your body’s already producing, which makes your natural tap shut off.
TRT also causes your sperm count to crash to near zero—a critical consideration for younger men who might want kids.
So, who should and shouldn't take TRT—and how do you know?
According to the leading experts I spoke with, if you’re an older guy—well north of 50—and you suffer daily from those negative effects, seeking out TRT is a reasonable, healthy course of action.
For example: You’re 65 and your testosterone has plunged to 250 ng/dl. You’ve most likely lost your sex drive and your ability to get a hard-on, and you feel constantly tired and depressed. Plus, you’re losing muscle mass and your bones are becoming brittle and prone to fracture. For you, TRT is a sensible option.
But if you’re a normal, healthy male in your 30s or 40s, you probably don’t need TRT.
“If you go in and say, ‘Well, you know, in the past 10 years I’ve gotten more tired, I’m having trouble keeping weight off…’ that’s simply not enough—it’s a natural phenomenon!” explains Jacques Baillargeon, Ph.D., an epidemiologist at the University of Texas Medical Branch at Galveston.
That’s not to say young men never need a T boost. According to Swerdloff, perhaps 5% of men suffer from a condition known as hypogonadism, which prevents these unlucky few from producing enough T on their own. For them, therapy makes sense.
Bottom line, if you’re unhappy with your daily life due to a possible lack of T, then TRT is something to consider. But, leading experts agree, first you need to visit a urologist or an endocrinologist—specialists more adept at diagnosing and treating hormone deficiencies than the average family doctor or low-T clinic—to have your blood-testosterone level checked. Doing so requires at least two blood tests, ideally after fasting for 12 hours and as close as possible to 8 a.m., when oft-fluctuating T levels are at their highest.
“A physician should have chemical evidence that a patient has a measurably low testosterone level” before TRT is administered, says Swerdloff.
Shockingly, about one in four men undergoing TRT never seeks a blood test, meaning that up to a quarter of low-T patients are treating a condition they may not even have. Nevertheless, T prescriptions are being handed out left and right.
“A lot of people are walking into doctors’ offices and asking for prescriptions, and doctors are complying, in part because they don’t want to lose patients,” says John Hoberman, author of Testosterone Dreams. “A lot of sloppiness and fraud comes when you just slosh this stuff out there and let every Tom, Dick, and Harry try it.”
And it’s not just old Toms, Dicks, and Harrys—those guys in the commercials trying to get their sex lives back on track— who are seeking out prescriptions for T.
“There’s a big interest in testosterone treatment among young, relatively healthy men, in order to enhance both appearance and strength,” says Swerdloff.
Let’s say you’re a healthy 35-year-old guy with an average T level of 668 ng/dl, and you want some AndroGel to get jacked: You should definitely think twice about it.
Sure, TRT can boost your testosterone by hundreds of points in as little as a few weeks; but it can take you only so far. Landmark studies at the Charles R. Drew University of Medicine and Science and McMaster University showed that if a man’s T levels are relatively higher but still in the normal range, he won’t build muscle any faster than a man with lower levels.
No, if you really want to see huge muscle gains, you’ll have to push your T well into the thousands—for which you’ll need something a lot more potent than AndroGel.
In other words, in no way should TRT be considered a legal alternative to steroids.
Other alternatives to TRT
The good news is, if you feel your testosterone could use a boost but aren’t considering TRT, you can increase your levels naturally by adjusting your workout, diet, and lifestyle habits.
At the gym, do more deadlifts and squats—leg-heavy exercises known to boost T. Eat more foods high in protein and vitamin D, such as steak, eggs, oysters, salmon, nuts, milk, and yogurt, and get a good night’s sleep, all of which help build muscle and up T production.
Not surprisingly, raising T naturally takes work. While TRT can raise testosterone in a matter of weeks, changes in habits may take months or even years to achieve the same result. But consider the other benefits your healthier lifestyle will bring—not the least of which will be better overall well-being with no fear of side effects.
In my case, my blood tests actually saved me from TRT.
A month after my initial visit, I was back in my endocrinologist’s office for the results of a follow-up blood test. Put off by the prospect of infertility, I’d been very reluctant to go the TRT route, and opted instead for a clomiphene citrate, or Clomid. Designed to stimulate ovulation in women, the pills have also proven effective at raising T levels in men with secondary hypogonadism—that is, men whose difficulty producing testosterone stems from problems in the hypothalamus or the pituitary gland. In many cases, Clomid can prod the body into upping its production of testosterone.
For me, it worked with a vengeance: A daily 25mg brought my masculinity roaring back. My T level nearly sextupled to 772 ng/dl—a dramatic enough improvement that my endocrinologist lowered the dose.
Most important, I now feel better. My aches and pains haven’t gone away completely, but they’re less noticeable than before, and overall I feel more energetic, confident, and, well, happy.
Thankfully, I wasn’t that low-T guy after all.