Whether you’ve talked about it in the weight room, read about it in a magazine, or seen a commercial on TV, chances are you’ve heard about testosterone replacement. The current media storm might lead one to believe this treatment is nothing but positive. But before you begin any kind of treatment, it’s important to understand the various therapies and discuss the pros and cons with your provider. If you think you may be low in testosterone, brush up on the basics before having that important conversation.

What is testosterone? What’s a “normal” level?

Testosterone is the hormone produced by the testicles that gives biological males characteristic traits like facial and body hair, a deep voice, and larger muscles. It’s also responsible for stimulating the growth of the penis at puberty, fueling libido, and playing a role in sperm production and bone growth.

Beginning around age 40, testosterone levels begin to fall by about one percent every year, but some men actually develop a condition known as hypogonadism, meaning the body doesn’t produce enough testosterone. This can occur for a variety of reasons, including injury or infection. For men with hypogonadism, testosterone replacement therapy may be the best course of treatment. But it may not be appropriate for many men who are simply experiencing a natural decline or have seen their testosterone levels fall due to an illness (like diabetes).

While a reasonably accurate estimation of normal testosterone levels range from about 300 to 900 nanograms per deciliter (ng/dL), there’s an ongoing debate regarding these parameters. This controversy is reflected in the fairly broad reference range used by various lab companies in the US.

How many men are affected by low testosterone?

Approximately one in every four men over the age of 30 experiences low testosterone levels, although only about one in twenty actually have clinical symptoms.

What are the symptoms?

In adult men, the symptoms of low testosterone include:

  • Low libido
  • Erectile dysfunction
  • Fatigue
  • Irritability
  • Depression
  • Trouble concentrating
  • Decreased muscle mass
  • Muscle soreness, and prolonged recovery times from exercise

What are the risks of low testosterone?

The risks associated with low levels of testosterone include:

  • Weakened bones
  • Depression
  • Erectile dysfunction
  • One study suggests a higher risk of death from heart disease and other causes

Additionally, low testosterone has been linked to diabetes, obesity, and high blood pressure, but it’s unknown whether it’s the cause.

Can testosterone replacement restore energy/libido/sexual function/bone and muscle strength?

The answers are still unclear. A recent study examining 308 men who were 60 years and older with low to low-normal testosterone levels found no difference between treatment and placebo groups in terms of sexual desire, erectile function, overall sexual function scores, partner intimacy, and health-related quality of life (there was a modest increase in intercourse satisfaction, but far less than what’s been observed in studies involving drugs like Viagra and Cialis). And another smallstudy looking at the impact of testosterone replacement on ejaculatory function in men with below-normal testosterone levels also found no significant difference between treatment and placebo groups.

However, an update from the Endocrine Society Clinical Practice Guidelines for Medical Hypogonadism in the Mayo Clinic Proceedings cites beneficial effects of testosterone replacement on osteoporosis, muscle strength, and symptoms of frailty, as well as sexual function and insulin sensitivity in men with diabetes and metabolic syndrome.

Why is testosterone replacement so popular now?

You may have heard of some of the purported benefits including improved libido, mood, muscle mass, and bone density. And while it can be helpful, testosterone replacement isn’t right for everyone. There is little research that demonstrates its effectiveness in men with already-healthy levels of testosterone, and the small studies that have been done show mixed results.

Other reasons for the piqued interest in testosterone replacement therapy include a rise in the number of prescriptions written by health care providers, as well as possible past under-diagnosis. In addition, the American Diabetes Association now recommends testosterone evaluations for men with diabetes, potentially prompting more men to seek help for low levels.

What are the risks associated with testosterone therapy?

The risks associated with testosterone replacement therapies include:

  • Increased risk of developing blood clots
  • Excessively high blood counts which can require removal to restore normal levels
  • Acne
  • Sleep apnea, or worsening sleep apnea if currently untreated
  • Enlarged breasts
  • Limited sperm production or testicle shrinkage
  • Infertility
  • Stimulation of noncancerous growth of the prostate known as BPH and possible growth of existing prostate cancer (the association between testosterone therapy and new prostate cancers is still unclear and remains an area of ongoing research)
  • Possible increase risk of heart disease, although the results are mixed and the risk remains unclear (The American Association of Clinical Endocrinologists recently reported on the potential overstatement of this risk by the FDA previously and advised revision)

What are the treatment options?

There a variety of ways testosterone replacement therapy can be administered. These include:


  • Pros:
    • Easiest therapies to administer
    • Very effective
  • Cons:
    • Higher cost
    • Possible irritation to skin or eyes
    • Potential of gel rubbing off on someone else, especially women and children


  • Pros:
    • Variable dosing regimens, with infrequent injections (from once weekly up to once monthly)
    • Relatively inexpensive
  • Cons:
    • Testosterone levels can be difficult to control (too high after injection, too low before next injection)


  • Pros:
    • Pills don’t have to be chewed or swallowed—they mold to the upper gum so eating and drinking is possible
  • Cons:
    • Irritation of the gums
    • Toothache
    • Bitter taste
    • Must be replaced every 12 hours

Intranasal (Natesto)

  • Pros:
    • Easy to use
  • Cons:
    • Must be administered 3 times a day
    • Cost

Are there any alternative treatment options?

If hypogonadism is not your issue, and you’re just looking to maintain healthy levels of testosterone, there are plenty of lifestyle changes you can make:

  • Get enough good quality sleep–you can get enough sleep without it being good sleep and that can still negatively impact testosterone levels–quality sleep is critical.
  • Maintain a healthy weight.
  • Exercise often (but not too much – excessive exercise can lower testosterone levels). Both cardiovascular and weight-lifting activities can be helpful.
  • Manage stress.
  • Eat a healthy diet with emphasis on leafy green vegetables, whole grains and lean proteins.
  • Reduce alcohol, caffeine and other stimulants.
  • Talk to your provider if you are taking opioids, glucocorticoids, and anabolic steroids, which can all cause a drop in testosterone.

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