Dr.Kim’s Guidelines for Low Testosterone Treatment

By Kim Crawford, M.D. Last updated: September 6, 2018
low testosterone treatment

Why Discuss Low Testosterone Treatment Now?

As a Functional Medicine doctor, about 2/3 of the therapeutic requests I receive involve either menopausal symptoms or symptoms of low testosterone. As an expert when it comes to low progesterone, low estrogen or low testosterone treatment, it seems men have many misconceptions about hormones. In this article, I’ll discuss testosterone replacement therapy risks and benefits including:

  • How testosterone works
  • What are the signs/symptoms of low-T A.K.A. male hypogonadism?
  • Why does testosterone decline?
  • What’s the latest on testosterone and heart disease?
  • What should my testosterone level be?
  • What’s the best way to replace testosterone?
  • Testosterone replacement and future fertility
  • Erectile dysfunction
How does Testosterone Work and What does it do?

Testosterone is the male sex hormone, just as estrogen and progesterone are the primary female sex hormones. Although women do indeed produce testosterone (and at some point, might need replacement), this article will focus on men.

In men, testosterone is the main hormone produced in the testicles and secreted by the testes. It promotes libido (sex drive), aggressiveness, and sexual desire. It also stimulates the growth of certain organs, the production of sperm, and nourishes all the tissue of the male urinary and reproductive systems. Testosterone promotes protein anabolism which is the use of protein to build muscle, skin, and bone, and mitigates against protein catabolism, or breakdown. It also regulates the production of prostaglandins, which (research shows) seems to keep prostate growth under control. 

The effects of testosterone are most pronounced during puberty. In fact, it brings on the enlarged larynx, thicker vocal cords, new body hair, increased muscle mass and increased oil-gland secretion by the skin commonly associated with puberty.

Some telltale signs of hypogonadism (“Low-T”)

Testosterone deficiency can cause memory, mood, and sleep issues, usually resulting in interrupted and unrefreshed sleep and next-day brain fog. Energy is also impacted as well, with an all-day feeling of sluggishness, which often includes lack of drive, inability to start an exercise regimen, and loss of muscle mass.

In addition, libido is down, and erectile dysfunction is possible, but (believe it or not) it’s usually not due to having a low level of testosterone. More often than not, if you have “E.D.” it’s from vascular disease and/or high glucose levels.

If you are experiencing the symptoms described above, there is the remote possibility of a testicular nodule that may or may not be serious. If you palpate one, seek medical help as quickly as possible. Here is a list of signs and symptoms:

  • Irritability
  • Depressed mood
  • Aches and pains in the joints
  • Poor sleep
  • Decreased energy
  • Decreased libido with or without erectile dysfunction
  • Osteoporosis if it goes on for a while
  • Loss of weight due to muscle mass loss and fat gain
  • Absence or regression of secondary sexual characteristics

What causes low testosterone?

Hormonally and physically speaking, your body peaks around age 25. We often assume things like a decreased libido, foggy memory, mid-life weight gain, hair loss, and wrinkles are simply a part of “getting older.” Even worse, that’s what most doctors think too! However, we can relieve these symptoms with the use of bioidentical hormones.

Before jumping into a discussion about hormone replacement, a thorough workup is necessary to rule out (or diagnose and then treat) excess weight issues, inflammation, tumors, medications, smoking, excess alcohol, diabetes, HGH deficiency, inactivity, toxins, food allergies, head trauma, groin trauma, pituitary or testicular tumors, leaky gut, silent autoimmune disease, and even high cortisol from excessive stress.

Low testosterone can be caused by previous use of testosterone for bodybuilding purposes. Many men with low testosterone levels have high cortisol because they are pushing themselves too hard. If you have been told you have “low T”, make sure your clinician evaluates your need for adrenal fatigue supplements (AKA adrenal axis dysfunction adaptogens and glandulars).

Further, a permanent interruption of the pituitary-testicular axis with “unresponsive testes” may be present after normal dosing for only a few months time. A great form of natural hormone balancing is to fix the underlying cause of the hormonal issue(s). When these problems are properly addressed, we can assess whether or not testosterone replacement is needed.

Addressing “andropause” is also necessary; which is the gradual waning of testosterone levels usually occurring in men in their 50’s, but sometimes as early as late 30’s.

Once symptoms and low testosterone levels have been confirmed, should men worry about an increased risk of heart disease if they replace their testosterone?

Testosterone and heart disease 

A couple of years ago, there was a big stir with editorials in the Wall Street Journal and New York Times; both reporting on a study that showed a correlation between testosterone replacement and coronary artery disease. That particular study was farcical; as the diagnosis of low testosterone was based on symptoms, not lab testing, and replacement was performed by primary care doctors who didn’t check post-treatment testosterone levels. Furthermore, cardiac risks pre-testosterone treatment were poorly documented. Indeed, a lot of chaos was created by one study which should not have been published. Here’s the reality.

Proven Effects of testosterone replacement

Hundreds of studies since the 50’s show that adequate testosterone helps prevent heart disease. For example, a recent comprehensive study reviewed men who had existing heart disease. Researchers studied 755 male patients, 58-78 years of age, who all had severe coronary artery disease and low testosterone levels. They were separated into three different groups, receiving various doses of testosterone, administered intravenously or by a gel.

At the end of the first year, 64 patients who weren’t taking any testosterone supplements had severe adverse cardiovascular events. This included only 12 who were taking medium doses of testosterone and nine who were taking high doses. After three years, 125 patients who had not received testosterone therapy suffered severe cardiovascular events, whereas only 38 medium-dose and 22 high-patients did.

Patients who were given testosterone as part of their follow-up treatment did much better than patients who had not been given testosterone supplementation. The non-testosterone-therapy patients were 80 percent more likely to suffer an adverse cardiac event. This study also confirms the findings of a previous study from the same researchers which found that testosterone therapy did not increase the risk of experiencing a heart attack or stroke for men with low testosterone levels and no prior history of heart disease.

Mayo Clinic’s Review of Tthe Effects of Testosterone Replacement

The Mayo Clinic published a large 2018 review of the effects of testosterone replacement, based on numerous studies. Here is a summary of their summary.

Randomized controlled studies confirm that testosterone replacement improves cardiac blood flow in men with chronic stable angina (chest pain) and chronic heart failure. These effects persist for at least one year. Testosterone is a coronary vasodilator as well as having other positive vascular actions on other arteries.

The same type of well-done studies have consistently shown that testosterone replacement therapy reduces fat mass and increases lean mass. The effect of testosterone on BMI plus waist circumference shows that benefits gradually accrue over several years. Testosterone is also beneficial for the regulation of carbohydrate and lipid metabolism, with a positive effect on metabolic pathways; all of which contribute to cardiovascular risk benefits. Further, testosterone replacement in men with type 2 diabetes and hypogonadism improves all-cause (including cardiac) mortality.

Endocrine and Urological guidelines for replacement of testosterone

There is a consensus of who needs treatment from the Endocrine and Urological medical communities. In short, they recommend therapy for men with symptomatic testosterone deficiency to either induce or maintain secondary sex characteristics such as muscle development, deep voice, and hair distribution on the chest and face and correct symptoms of hypogonadism. They (of course) strongly discourage starting testosterone treatment in patients who have fertility plans. Contraindications to therapy also include prostate cancer, palpable prostate nodule(s), prostate-specific antigen level > 4 ng/mL or a PSA level greater than 3 ng/mL in men at increased risk of prostate cancer without further urological evaluation. Included in the restriction on therapy are an elevated red blood cell count, untreated sleep apnea, uncontrolled heart failure, and even (Endo guidelines) stroke or heart attack within the last six months.

Regarding actual levels of testosterone to achieve, it is suggested that treating Physicians aim for testosterone concentrations in the mid-normal range. That would be 590 ng/dL of total testosterone and 12.35 pg/mL of free testosterone. However, other journals don’t discuss free testosterone and instead, recommend a total testosterone level of 350 ng/dL. Wow, that’s a low-ball recommendation in the opinion of most hormone-replacement experts. Let me clear things up here.

Adequate Levels of Testosterone

As clinicians, we are seeking to replace testosterone to levels where our male patients will have good sleep, energy, libido, optimized moods and optimal metabolic results from testosterone replacement. Too little yields inadequate clinical results; too much might compromise glucose control; the whole “roid rage thing” involves huge doses which is a lot more than a legitimate doctor would prescribe. Those of us in the Functional and Anti-aging community look at symptoms and aim for a free testosterone of about 12-13 pg/mL. 

We also take into account a man’s albumin and SHBG (sex hormone binding globulin) levels, as these will affect the amount of “free and unbound” testosterone which is the best number to calculate if we’re looking for “the magic number.” There is not always a good correlation between total T, free T, and free and unbound T which is why I always say you need a hormone specialist to do any hormone replacement correctly.

What’s the best form of treatment?

There are two types of hormones available for any sort of hormone replacement therapy: Synthetic hormones and Bioidentical hormones. This is important to know because of potential side effects.

Bioidentical hormones are made to yield products which are biological replicas of the substances produced by our bodies. This is why they do not produce undesirable side effects when administered correctly.

In contrast, synthetic hormones are not biologically identical replicas. As a result, their use can result in severe side effects, as evidenced by clinical studies. Furthermore, bioidenticals have been shown by most clinical studies to be protective when administered properly. This can only be accomplished by a physician who has specialized in this field.

In addition, there are various forms of testosterone replacement therapy including commercial gels or compounded creams, injectables and pellets. Commercially available gels will get men to testosterone levels which (as I will discuss) are “medically acceptable” but not to levels of optimal symptomatic control. Compounded topicals can be nicely bioidentical but come with the “hassle” of having to air dry for 20 minutes plus the concerning factor of transfer to other humans (children and spouses) and even pets!

Then there is the weekly IM or sometimes sub-q injection which is my preferred delivery system. I choose to use testosterone cypionate because after one biochemical “cleavage” it is considered one of the most bioidentical hormones we use. Lastly, there are pellets, which generally last 3 months. The problem with pellets is they are like a “Three Bears” book. Let me explain. The first month the testosterone released from the pellet is “too high”; the second month is “just right”; and the third month is “too low”. Three bears, right?

What if I have low T and want a family?

You need a sperm count and if you are lucky enough to have a normal one, you need to deep freeze your sperm. However, if your count is low, then we can try to amp it up with Clomid and HCG (human chorionic gonadotropin); and then try again. If we’re lucky you’ll have a decent count or a “combinable samples count” and you can freeze your sperm then. To emphasize, do not start taking testosterone if you are planning to have children.

What if I have E.D. and my T is normal?

Contrary to popular belief, low testosterone is less of a cause of erectile dysfunction than diabetes, pre-diabetes (1 and 2) or vascular disease. If you have E.D., a thorough check-up and lab testing are necessary. But, don’t fret; at least not until you know the extent of what’s the matter. Functional medicine doctors who deal with this issue can treat high blood sugar with integratives (and even help you achieve normal blood sugar levels) and even reverse some or most “soft” coronary plaquing.


 2018 Feb;50(1). doi: 10.1111/and.12801. Epub 2017 Mar 10.

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Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline.

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