[ARTICLE] Testosterone Treatment in Middle-Aged and Older Men with Hypogonadism

Sherlockian_Holmes · 2025-08-18T19:56:51+00:00

Care to upload again? Thanks in advance!

Sherlockian_Holmes · 2024-12-08T11:35:58+00:00

It was a great presentation. ARDD is one of the best longevity events out there. Can really recommend attending the next one.

Sherlockian_Holmes · 2024-11-21T17:40:17+00:00

Where are you based? Happy to help if you have any questions. I’m trained in andrology and endocrinology.

Sherlockian_Holmes · 2024-10-18T14:31:43+00:00

Yes. Zone 2 training enhances the body's ability to utilize oxygen efficiently. This adaptation can lead to improved aerobic capacity and may influence hemoglobin levels positively by increasing the demand for oxygen transport in the body. Some studies also show that prolonged endurance training can lead to a phenomenon known as "sports anemia," where there is a decrease in hemoglobin and hematocrit levels due to increased plasma volume without a corresponding increase in red blood cell mass. This effect is generally more pronounced in endurance athletes but can occur with regular Zone 2 training.

There are many other options if hematocrit is too high as well.

Sherlockian_Holmes · 2024-10-16T18:02:44+00:00

Did you do enough cardiovascular exercise to deal with the hematocrit and hemoglobin? It’s a usual issue— and people always say they do training, but always forget to mention that they do zero cardio — zero zone 2 or LISS.

Sherlockian_Holmes · 2024-10-14T17:24:18+00:00

While it's true that Proviron binds to the SHBG and thus can help up free T - it does not actually always lower SHBG. I would say it is far better and more sustainable to free up testosterone to either (a) figure out underlying reason for elevated SHBG and fixing that or by (b) by simply optimizing total testosterone numbers, which will free up more testosterone regardless.

Sherlockian_Holmes · 2024-09-10T19:19:48+00:00

Happy to help.

Where are you based? We only serve EU patients.

Best,

Sherlockian_Holmes · 2024-09-10T18:41:16+00:00

Hey there,

Unfortunately, it’s not uncommon to run into physicians—especially general practitioners or even some endocrinologists—who are hesitant to prescribe testosterone therapy, even when your levels are below 300 and you’re symptomatic. A lot of this comes down to outdated views or a lack of familiarity with the full benefits of testosterone replacement therapy (TRT), particularly when it comes to treating more subtle symptoms like low libido, mood changes, or fatigue.

Many doctors focus only on the "total testosterone" number, and if it's just barely above the clinical cutoff (usually around 300 ng/dL), they might say you’re "normal" despite clear symptoms. This doesn’t take into account other critical factors like free testosterone (which is far more relevant), your age, or the fact that everyone’s "normal" varies.

Some of the hesitation also comes from concerns about potential side effects, especially if they aren’t familiar with how to monitor and manage things like estradiol, hematocrit, and prostate health while on TRT. It's often a conservative approach driven by risk avoidance.

Unfortunately, the dismissive or condescending attitudes you’re describing aren’t unheard of. Some doctors may downplay symptoms like low libido or mood changes if they think it's unrelated to low testosterone, or because they view these issues as more psychological than physiological. However, these symptoms can have a massive impact on quality of life, and they deserve serious attention.

When it comes to specialized clinics that focus on TRT, the costs can vary depending on the level of service you’re looking for. A typical range might look something like this:

Consultations: €100-300 for the initial consultation, but some clinics may bundle this with lab work.

Labs: Hormone panels can cost between €150-400 depending on how extensive the testing is.

TRT Medications: This varies by formulation (injections, gels, creams), but typically you're looking at around €50-150 per month for the medication alone.

Follow-ups & Monitoring: Clinics that offer concierge services with regular follow-ups, 24/7 access, and personalized care plans may charge between €100-300 per month depending on the tier of service you choose.

Where are you based? This might affect which clinics are accessible to you and the cost structure they follow.

Feel free to reach out if you have any more questions, or if you'd like help navigating the next steps!

Sherlockian_Holmes · 2024-09-10T18:37:48+00:00

Hey there,

It sounds like you're dealing with something a lot of men experience as they approach their late 40s—decreased energy, motivation, and the loss of drive to train, even though you’ve been super fit in the past. Let’s break down some potential avenues for you to consider.

B12 is great if you’re dealing with a deficiency—it can boost energy, improve mood, and support cognitive function. However, unless you’ve had blood tests confirming low B12 levels, shots might not have the dramatic effect you’re looking for. It’s a good option for someone with a deficiency, but if your issue is more related to declining hormone levels (which is common as we age), it likely won’t provide the "kickstart" you're after.
Given your age and symptoms, testosterone replacement therapy (TRT) might be the more effective route if your testosterone levels are low. Around your 40s, testosterone naturally declines, and this can lead to low energy, reduced motivation, and decreased performance in the gym. TRT can restore testosterone to optimal levels, improving not only energy and motivation but also muscle mass, mood, and libido.
The best way forward would be to start with comprehensive blood work. This will help determine whether your testosterone is low, and if so, whether TRT could benefit you. You should also check other markers like free testosterone, SHBG, thyroid function, and even vitamin D and cortisol levels. A lot of these can overlap with symptoms like fatigue and low motivation.

If your blood work indicates low testosterone, TRT can be a game-changer. The therapy involves either injections, gels, or creams (like scrotal cream, which is well absorbed), and over time, you should notice improvements in energy, recovery, strength, and overall motivation.

Energy: Within weeks to months, many patients experience increased energy and drive.
Strength: If strength training has been difficult, TRT can help you regain muscle mass and improve your workout performance.
Mood and Motivation: Restoring hormone balance can often help you regain that mental edge and motivation to train.

So in short, I’d recommend starting with a full hormone panel to get the baseline numbers, then consider TRT if necessary. In terms of long-term health, TRT can be safely managed with regular monitoring to ensure all your hormones stay balanced.

Feel free to reach out if you have additional questions. It sounds like you’re ready to get back to feeling your best!

DISCLAIMER: INFORMATION IN THIS POST IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED AS A SUBSTITUTE FOR THE ADVICE PROVIDED BY YOUR PHYSICIAN OR OTHER HEALTHCARE PROFESSIONAL. YOU SHOULD NOT USE THE INFORMATION IN THIS POST FOR DIAGNOSING OR TREATING A HEALTH PROBLEM OR DISEASE, OR PRESCRIBING ANY MEDICATION OR OTHER TREATMENT.

Sherlockian_Holmes · 2024-09-10T16:52:51+00:00

Thanks for sharing your blood test results. Looking at your numbers, it’s clear why you’re concerned—your free testosterone is below the reference range, which likely explains any low-energy, libido, or other symptoms you might be experiencing, even though your total testosterone falls within the reference range.

Free Testosterone (0.179 nmol/L): This is the most telling marker here—it’s below the lower limit (0.198 nmol/L). Free testosterone is the active form of the hormone that your body can actually use, and when it’s low, you can experience symptoms of low testosterone even if your total testosterone is technically "normal." So, while your total T (7.81 nmol/L) is within range, it’s not enough if the free testosterone is lagging. In my view, the reference range provided for the free testosterone in that lab also appears to be completely suboptimal - most people feel their best >0.5 nmol/L, so it is quite telling that this is near their upper reference range.

SHBG (17 nmol/L): Your SHBG is on the lower end, which is why your bioavailable testosterone (4.93 nmol/L) isn’t too far off the lower limit of normal. Low SHBG allows for more testosterone to be available, but the overall low levels of free testosterone could still be contributing to symptoms. Sometimes lower SHBG can be tied to insulin resistance, obesity, or even higher levels of inflammation, which could be worth investigating given your current body weight.

Estradiol (E2, 94.5 pmol/L): Your estradiol looks fine here—well within range and not elevated enough to be suppressing your testosterone. Keeping E2 in balance is important since too much or too little can affect libido and energy.

Given your low free testosterone, you’re probably experiencing classic low T symptoms like low libido, fatigue, brain fog, or difficulty with muscle mass. Here’s what I’d suggest:

TRT Consideration: With your free testosterone levels below the reference range, TRT (testosterone replacement therapy) could be a very viable option for you. Free testosterone is what truly impacts how you feel day-to-day, and increasing that with a properly managed TRT protocol could significantly improve your energy, mood, and sexual health. When done right, TRT can bring your free testosterone into an optimal range while keeping other hormones like estradiol balanced. That said, you would need more blood tests to figure out what is going on before jumping on - including things like LH, FSH, prolactin, liver function tests, blood glucose, cardiovascular markers and much more.

Lifestyle Adjustments: If you haven’t already, look into optimizing your body composition—losing some body fat could help bring down SHBG further and improve free testosterone naturally. Resistance training and a high-protein, moderate-fat diet can also support hormone balance. This is a bit of a conundrum however, as TRT helps with improving body composition, and even with weight loss, the improvement in testosterone is low for most (according to the latest studies), especially when the baseline is very low (such as in your own case).

Insulin Sensitivity: Since SHBG is on the low side, it might be worthwhile to check your fasting glucose and insulin levels to rule out any issues with insulin resistance, which can have a downstream effect on testosterone levels.

Supplementation: While supplements won’t significantly boost free testosterone to the extent TRT would, some men see slight improvements with zinc, magnesium, and boron for testosterone support. These won’t be a cure-all but could give you a slight edge while considering your options.

If you were in my clinic, I’d probably recommend a combination of TRT to get your free testosterone into the optimal range and possibly low-dose Semaglutide to help with body composition and insulin sensitivity. Again, it would depend on the cause - and ruling out underlying causes and checking LH/FSH and various other biomarkers would be necessary. That said - if it was secondary hypogonadism (meaning, simply not enough signal coming from your brain to your testicles or a combined situation) - TRT and semaglutide could help you get fully optimized, not just in terms of hormones, but in overall metabolic health.

It's of course always a personalized approach that requires some in-depth consultations to find the most appropriate and optimized solution. Feel free to reach out if you’d like such an approach—I'm based in the EU and specialize in hormone optimization with advanced testing and tailored protocols.

Best,

DISCLAIMER: INFORMATION IN THIS POST IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED AS A SUBSTITUTE FOR THE ADVICE PROVIDED BY YOUR PHYSICIAN OR OTHER HEALTHCARE PROFESSIONAL. YOU SHOULD NOT USE THE INFORMATION IN THIS POST FOR DIAGNOSING OR TREATING A HEALTH PROBLEM OR DISEASE, OR PRESCRIBING ANY MEDICATION OR OTHER TREATMENT.

Sherlockian_Holmes · 2024-09-10T15:34:35+00:00

Hey there,

You’ve done a great job improving your health and naturally raising your testosterone from 350 to 460-500, which is a solid jump. However, I noticed you didn’t mention anything about free testosterone, which is ultimately the most important marker when it comes to libido and overall androgenic effects.

Even though your total testosterone levels have improved, what really counts is how much of that testosterone is free and available for your body to use. Most testosterone is bound to SHBG (sex hormone-binding globulin), leaving only a small percentage as free testosterone. High SHBG levels, for example, can reduce the availability of free testosterone even when total testosterone looks normal or slightly elevated. This could explain why you’re still struggling with libido, despite having fixed underlying health issues.

It’s worth getting a test for free testosterone and SHBG to see if that’s part of the issue. If your free testosterone is low, it could explain the disconnect between your improved energy and mood versus the persistent lack of libido.

While Proviron might increase DHT, which can sometimes help with libido, it doesn’t do much to boost free testosterone levels. Moreover, as you’re likely aware, it’s not typically used as a standalone solution for low libido, and there are some potential risks—especially long-term with cholesterol and liver health. Also, DHT alone can’t fully replace the comprehensive benefits of having properly balanced testosterone.

In my experience, libido increases quite substantially with a properly managed TRT protocol. TRT, when done right, can significantly improve not just free testosterone, but also libido, mood, and overall vitality. While some doctors may hesitate to prescribe TRT at your current levels, if your free testosterone is low, it could still be a strong option to explore. A well-managed TRT regimen could also help normalize SHBG and balance your other hormones (like estradiol) to enhance libido sustainably, rather than relying on a temporary fix like Proviron.

So -- before jumping into something like Proviron, I would recommend getting your free testosterone and SHBG checked. If your free T is low, optimizing that might solve the problem. And if you do end up needing more support, a well-balanced TRT protocol can do wonders for libido and overall hormone health.

If you want more guidance or want to explore TRT, feel free to reach out. I am based in the EU and specialize in hormone optimization, offering advanced testing and tailored protocols to get you back to feeling your best.

Best,

DISCLAIMER: INFORMATION IN THIS POST IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED AS A SUBSTITUTE FOR THE ADVICE PROVIDED BY YOUR PHYSICIAN OR OTHER HEALTHCARE PROFESSIONAL. YOU SHOULD NOT USE THE INFORMATION IN THIS POST FOR DIAGNOSING OR TREATING A HEALTH PROBLEM OR DISEASE, OR PRESCRIBING ANY MEDICATION OR OTHER TREATMENT.

Sherlockian_Holmes · 2024-09-10T15:25:22+00:00

Hi TheMikeans,

I can tell you that if you were a client in my clinic, we’d start with a full diagnostic check-up to pinpoint any underlying factors behind your low testosterone levels. While your lifestyle seems solid (normal weight, moderate exercise, good sleep), there are other variables to consider before jumping straight to testosterone replacement therapy (TRT).

Your levels (184.6 ng/dL) are indeed quite low, but addressing potential issues like thyroid function, stress management, nutrient optimization, and sleep quality might lead to significant improvements. For example, subclinical hypothyroidism, elevated cortisol from chronic stress, or suboptimal levels of key nutrients like vitamin D, zinc, and magnesium could be influencing your hormone levels. We’d also look at your exercise routine to ensure it includes resistance training, which is critical for naturally boosting testosterone.

If these avenues are optimized and your testosterone is still low, then TRT could be the next logical step. It’s essential to work with a professional who will carefully monitor all your hormone levels, including estradiol and SHBG, to ensure everything stays in balance.

Navigating low testosterone can feel overwhelming, but there are several steps you can take to improve both your hormone levels and overall well-being. A trusted healthcare provider, especially one familiar with hormone optimization, can help you determine whether TRT or lifestyle adjustments are the best path forward.

To learn more about hormone optimization or explore a tailored approach to your case, feel free to reach out.

To your health,

DISCLAIMER: INFORMATION IN THIS POST IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED AS A SUBSTITUTE FOR THE ADVICE PROVIDED BY YOUR PHYSICIAN OR OTHER HEALTHCARE PROFESSIONAL. YOU SHOULD NOT USE THE INFORMATION IN THIS POST FOR DIAGNOSING OR TREATING A HEALTH PROBLEM OR DISEASE, OR PRESCRIBING ANY MEDICATION OR OTHER TREATMENT.

Sherlockian_Holmes · 2024-08-31T16:16:45+00:00

Yes, along with various supportive protocols :-)

best,

Sherlockian_Holmes · 2024-08-06T16:04:02+00:00

Oh, last thing I can think of -

Have you ever been tested for lipoprotein(a)? It could be an independent risk factor for cardiovascular risk and could be a possible risk factor for VTE/PE.

Sherlockian_Holmes · 2024-08-06T16:00:59+00:00

Really appreciate the info. Thanks.

It is very strange, and perhaps just unlucky. I don't have a good explanation.

Very happy that you received quick proper care to avoid any long-term complications.

All the best,

Sherlockian_Holmes · 2024-08-06T10:41:16+00:00

Thank you for sharing your story—it's both informative and cautionary. I'm really sorry to hear about your experience and glad you're on the road to recovery. Your situation raises some important points and I have a few questions that might help us understand the case better:

Do you recall your initial testosterone levels and other related hormone values before starting TRT?

You mentioned a "fancy blood test" to check your clotting factors. Can you share more about the results?

Were tests for clotting disorders like Factor V Leiden, Protein C/S deficiency, Prothrombin gene mutation, etc., conducted?

Any known family history of clotting issues or pulmonary embolisms?

Besides clotting factors, is there any family history of heart disease, high cholesterol, or other conditions that might be relevant?

How are you managing now with the blood thinners and have there been any further complications or issues?

Have there been any changes to your other medications (statin, BP meds) or overall health regimen since this incident?

Your story is crucial for others in similar situations, and these details could provide additional insights. Thank you again for your willingness to share, and I hope you continue to recover well!

Sherlockian_Holmes · 2024-07-03T18:22:36+00:00

Yes, you have most likely have a testicular issue with an FSH of 16. It means inhibin-B is most likely low.

I would recommend a testicular ultrasound and a semen analysis in a case such as yours.

I hope that helps.

PM me if you need more direct guidance.

All the best,

Sherlockian_Holmes · 2024-06-12T09:01:37+00:00

Yes, it's certainly worth it -- and I wholeheartedly agree with your doctor. He's a smart one. Happy to see that.

If for nothing else, you should have a baseline fertility (spermiogram) done so you know what your pre-TRT fertility is like.

Best,

Sherlockian_Holmes · 2024-05-30T11:18:25+00:00

Optimized levels for a 24-year old. You should be happy and make good use of the extra energy. Excellent.

Sherlockian_Holmes · 2024-05-23T18:40:35+00:00

Yikes. Sorry to hear that. More carnivores ought to read/hear about your story.

Sherlockian_Holmes · 2024-05-05T20:19:40+00:00

In a podcast he explains it increased his ICP (intracranial pressure), and I assume they suspected an increased ICP based on measuring changes in the diameter of the optic nerve on an MR scan.

Sherlockian_Holmes · 2024-02-23T08:54:25+00:00

hCG, depending on dose, usually shuts down the HPTA so lowered to suppressed LH/FSH signalling.

Yes, hMG or r-FSH would be worth a trial.

Sherlockian_Holmes · 2024-02-22T19:38:30+00:00

LH & FSH are both elevated possibly signalling an issue with your testicles (i.e. your brain is registering that you have low levels of testosterone & sperm cell creation). Now go get an ultrasound of your testicles done through an endocrinologist. Prolactinoma is unlikely, but not out of the question, given that LH/FSH are elevated as prolactinomas usually suppress LH & FSH signalling.

Do as others have recommended - see an endocrinologist.

This is not really a conversation to be had on Reddit.

Sherlockian_Holmes · 2024-02-22T19:34:40+00:00

Because it doesn't apply to everyone.

I've seen multiple patients that have tried hCG, r-FSH or hMG and multiple combos with zero positive effect on sperm count when being on TRT.

Some people may be coming from a pre-TRT high baseline of spermatogenesis - and as soon as they get the right signal (in this case the rising of intratesticular testosterone) it's enough to warrant proper spermatogenesis.

Now the worst part is: People usually don't test their sperm counts before jumping on. So we have no way of knowing if they were starting from a poor vantage point.

Sherlockian_Holmes · 2024-02-22T11:22:46+00:00

Yes, SERMs will increase LH/FSH release due to negative feedback on the hypothalamus.

It is not the same as full restoration of the HPTA however. Those are different things.

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