Low testosterone — symptoms, the workup, and the honest evidence on treatment.

Symptoms that are actually related to low testosterone

Low T symptoms overlap with many other conditions — sleep apnea, depression, thyroid disease, stress, poor sleep, and just getting older. Symptoms most specific to low T:

• Reduced libido (sex drive)
• Erectile dysfunction, especially with reduced morning erections
• Decreased energy / fatigue
• Loss of muscle mass and strength despite stable diet and activity
• Increased body fat, especially around the midsection
• Mood changes — irritability, feeling "flat"
• Poor concentration or mental sharpness
• Reduced body and facial hair
• Hot flashes (less common, but occur in significant low T)

Notice: "I feel tired all the time" alone is not a reason to treat with testosterone. Neither is "I've gained 15 pounds." These are nonspecific. They might be low T; they might be any of 20 other things.

The proper workup

1. Morning blood test

Testosterone peaks in the early morning. A meaningful testosterone level must be drawn before 10 AM, ideally two mornings on different days to confirm. A single low reading isn't enough.

2. The full panel, not just total testosterone

Testosterone in the blood is mostly bound to proteins and inactive. What matters is free (bioavailable) testosterone. A good workup measures:

• Total testosterone
• Free testosterone or bioavailable testosterone
• SHBG (sex hormone binding globulin)
• LH and FSH (pituitary hormones)
• Prolactin
• Estradiol
• Complete blood count
• PSA (especially for men over 40)

3. Evaluate the cause

Based on the full panel, we determine whether:

• Primary hypogonadism — the testes themselves aren't making enough testosterone (high LH/FSH with low T).
• Secondary hypogonadism — the pituitary isn't signaling the testes properly (low LH/FSH with low T). This can sometimes be reversible.

Common reversible causes: obesity, poor sleep / untreated sleep apnea, chronic opioid use, chronic stress, certain medications. Addressing these often restores testosterone without any supplementation.

Treatment options

Lifestyle first (for many patients)

A real chunk of "low T" resolves with:

• Weight loss — fat tissue converts testosterone to estrogen. Losing 10–20% of body weight often raises testosterone substantially.
• Sleep apnea treatment — untreated sleep apnea is a major suppressor.
• Resistance training — strength training raises testosterone.
• Addressing chronic stress, alcohol use, or recreational drug use.

Testosterone replacement therapy (TRT)

For men with true hypogonadism and real symptoms, TRT is effective. Forms:

• Intramuscular injection — weekly or every-other-week. Most common, most cost-effective.
• Topical gel — applied daily. Must avoid skin contact with partners and children.
• Subcutaneous pellets — implanted every 3–6 months. Stable levels but requires a minor procedure.
• Nasal gel or buccal tablets — less commonly used.

Response is usually noticeable within 4–8 weeks. Energy and libido respond first; body composition changes take months.

Alternatives that don't use testosterone

For men who want to preserve fertility or avoid direct testosterone:

• Clomiphene citrate (Clomid) — stimulates the body's own testosterone production by affecting the pituitary. Works best in secondary hypogonadism.
• hCG — directly stimulates the testes.
• Anastrozole — prevents excess conversion of testosterone to estrogen (useful in specific scenarios).

The honest trade-offs of TRT

Testosterone replacement isn't free of consequences. Worth knowing before you start:

• Fertility suppression. TRT shuts down the body's own sperm production. If you might want more children, we plan differently.
• Thicker blood (erythrocytosis). TRT raises red blood cell count; we monitor with periodic labs. Sometimes requires blood donation or dose reduction.
• Potential for acne, mood fluctuation, and water retention depending on dose.
• PSA monitoring. TRT doesn't cause prostate cancer, but it can accelerate an existing one. We check PSA before starting and periodically afterward.
• Commitment. TRT usually isn't a short-term trial — once the testes stop making testosterone, restarting them can be slow.

What to expect from a consultation

If you come in for low T evaluation, Dr. Childs will ask about symptoms in detail, review your current health and medications, and order the full blood panel. If levels are clearly low and symptoms are specific, we'll discuss treatment options at a follow-up. If the picture is unclear, we'll often focus first on the reversible factors before committing to long-term therapy.