Feeling Sluggish? Not Quite Yourself? Get Your T Tested
You have a range of testing options, but a few rules apply to all: get two tests on two different days to arrive at an average, and aim to test in the morning when your T level is highest. Levels can fluctuate up to 40% during the day
masculinity is power in a lot of ways,’ says Carole Hooven, an evolutionary biologist at Harvard and author of T: The Story Of Testosterone, The Hormone That Dominates And Divides Us. ‘It’s dominance, it’s powerful, it’s sexy, and who doesn’t want more of that?’
The trouble is, many men see their T level begin to decline to varying degrees after about age 35, slipping slowly as they ease into midlife. It becomes harder to keep (or get) muscle and far easier to accumulate fat and, perhaps as a result, we, like Alam, end up feeling a bit blah in various areas of our lives. Officially, he was diagnosed with hypogonadism, which basically means ‘no balls’. It wasn’t that he lacked testicles; it’s just that they were failing to produce a normal amount of testosterone. #DeezNuts had checked out.
His situation was not unique. With a little digging, Alam discovered that an estimated 20% of his fellow under-40 men have a low testosterone level, defined as below 264. More concerningly, testosterone levels in younger men appear to have fallen across the board. One US study published in 2020 found that the average testosterone level in men aged 15 to 39 years old had dropped from 605 in 1999-2000 to 451 in 2015-2016, representing a 25% decrease in just 15 years. A study of Danish men showed similar results, with a notable drop among men born in the 1960s compared with those born in the 1920s. Testosterone deficiency is more likely to affect men who have a higher BMI or type 2 diabetes. In the UK, sperm counts, which are related to testosterone, have been plummeting for decades.
Odds are, your own body has been naturally suppressing your T for the past year or two. It’s an evolutionary imperative in times of crisis: why make babies when the world is a mess? Joseph Alukal, head of NewYork-Presbyterian’s new men’s health programme, has been telling patients for years that if the Bronx Zoo tested the T level of any social animal that’s newly confined, underfed and agitated – even an alpha male – it will have crashed, because the body curbs the sex drive in times of stress. ‘In the last year,
‘Testosterone signifies masculinity, which is power in a lot of ways’
the universe ran this experiment on all of us,’ he says.
Covid-related mind-body traumas and weight gain may be accelerating the low-T spiral, particularly for guys in their forties struggling with other societal stressors, too. ‘Men are thinking about their changes with age and feeling like they’re losing a bit of their edge, especially in the workplace,’ says Peter Gray, a professor of anthropology at the University of Nevada, Las Vegas. ‘Someone in their forties might think: I still need to go prove my worth in society. I’m too young to give up. But now I fall asleep early on a Friday night – what’s going on? And is there something that I can take that can help address this?’
Indeed, there is. Thanks to the wonders of modern pharma, testosterone is available in many forms, from creams to gels to shots in the arm at varying doses. And it’s no longer very hard to get, either. Even in the UK, testosterone can easily be purchased online. While consulting with your GP is advised, anyone with a computer or smartphone can get some extra T into their system with the right website.
Safety concerns about possible increased risk of prostate cancer and cardiovascular disease, which prompted dire warnings for decades, have faded in the face of more substantial evidence linking low testosterone levels to greater risk for all kinds of bad stuff, up to and including early death.
One large Canadian study found that men who had undergone testosterone replacement therapy for more than 16 months actually had less chance of prostate cancer, cardiac events and death than men who’d had it for shorter periods (or not at all).
Doctors are also discovering that the benefits of testosterone – helping men build muscle and lose fat – could help treat other problems. In a recent clinical trial in overweight men with metabolic syndrome (a cluster of symptoms related to metabolic health, including obesity and poor cholesterol), testosterone was found to help prevent them from diabetes, says study co-author Gary Wittert, a professor of medicine at the University of Adelaide in Australia, who has studied hormones for decades.
In a 2016 study, researchers conducted a series of clinical trials in a group of 790 older men with very low T levels. Testosterone supplementation was shown to increase bone density and strength, and subjects reported improved sexual function in the first year.
They also didn’t exhibit increased cardiovascular risk, although the number of subjects was too low and the study too short to draw any firm conclusions. All in all, these were some pretty amazing findings.
But that same 2016 study also revealed some of the ways that testosterone falls short in the miracle-drug department. The men on testosterone didn’t perform significantly better on most tests of physical function; they also didn’t see much improvement in their mood or cognition – two of the oft-cited benefits of testosterone therapy.
This trial – like most research into testosterone for anti-ageing purposes – was done in a population of older men (all over 65) with very low testosterone. Those men benefit in specific ways that might be different from a younger guy’s experience. So where are the studies in younger and middle-aged guys? The 39-year-olds who are signing up for testosterone treatment online? ‘We’re doing that experiment in the wild right now,’ says Professor Hooven, ‘whether we admit it or not.’
Alam saw a way to turn his diagnosis into a business: offer male hormone therapy, but in a clean, safe, medically responsible way. A few quick clicks on Hone’s website and a $45 (around £33) testosterone test kit will soon land on the enquiring man’s doorstep. Users consult a doctor, then squeeze a few drops of blood on to a card and send it back to be tested for eight different hormones and biomarkers (all related to testosterone), with a follow-up test a couple of weeks later to confirm the results and assess prostate and cardiovascular health.
(In the UK, Superdrug offers a similar service.) Then comes another discussion with a doctor to determine whether or not hormone therapy is required and, if so, what kind is best. Alam takes a relatively low dose of 50mg per week split between two injections (or about half the standard dose used in testosterone replacement therapy). In comparison, competitive bodybuilders might inject between 500 and 2,000mg per week.
With testosterone top-ups so easily available – and seemingly safe to use – the question then becomes: why not take it? Answer: because you might not even need it.
Lifestyle Matters
Besides the fact that they are about the same age, Ryan Hall, 39, has almost nothing in common with Saad Alam. Whereas Alam is an entrepreneur with a master’s in public health and an MBA, Hall is a former world-class runner with multiple top-10 finishes at major marathons, including the 2008 Olympics in Beijing.
But just like Alam, Hall was battling his own extremely low testosterone level. This might seem strange for an elite athlete, but during his career, he regularly tested in the 150 range, which is well below the lower end of normal for a man in his thirties. Even though
Covid-related mind-body traumas may be accelerating the low-T spiral
‘If you start hormone replacement, you’re in it for the long haul’
he was finishing marathons with the lead pack, he felt terrible. ‘I felt like a walking dead man, just tired all the time,’ he says. ‘All I did was sleep, eat and train.’
Anti-doping rules made testosterone therapy off-limits while he was competing, but after he retired in 2016, Hall began looking into it seriously. ‘I knew I didn’t want to keep living with such low hormone levels,’ he says.
Testosterone replacement seemed like an obvious, easy solution. But it also became less enticing when
Hall discovered that taking extra testosterone has the unfortunate side effect of suppressing a man’s natural testosterone production – and, not incidentally, often shrinking the testicles – as the body senses that it has enough of the hormone already. After a couple of months, testosterone and sperm production shut down completely. Hall found that to be a deal breaker. ‘I got curious about what was causing my low testosterone,’ he says. ‘Was it physiological, something inside of me? Or was it my lifestyle?’
Bingo. Multiple studies have found that high-volume endurance training, such as serious running and cycling, can depress a man’s testosterone level, sometimes drastically. Hall stopped running almost entirely and began lifting weights daily. He also worked on improving his sleep. As a half-starved endurance athlete, he’d kept himself very light, a skinny 10st on his 5ft 10in frame. So he allowed himself to eat more calories. Between that and the weightlifting, he bulked up to a muscular 13st; in Instagram photos now, he’s almost unrecognisable compared with his marathoning days. And slowly but surely, his testosterone climbed from below
200 up to 600 – in the normal range for the first time in his life. ‘If you start hormone replacement, you’re in it for the long haul,’ he says. ‘So why not first try to raise it naturally and get it into a good spot?’
Ups And Downs
On his own, Hall had discovered a crucial fact about testosterone, which is that it fluctuates – continually – in response to things that are happening in the body or the environment. These changes can occur over months and years, as they did with him, or in mere seconds. Did an attractive female walk by? Your testosterone probably just went up. Are you competing with another guy for a promotion, or even a parking spot? T boost. Did you win a tennis match against your best frenemy? T boost. Are you fighting
a cold or the flu? Your T level is likely going to take a hit. Even the time of day matters: testosterone is typically highest in the early morning and then declines steadily throughout the day, which is why ‘evening wood’ is not really a thing.
Even as guys look to testosterone to revive their flagging libido, it turns out that sex itself can boost testosterone levels – thinking about it, having it or even just watching it. In one of the more intrepid hormone studies ever done, two female researchers working with Professor Gray ventured into a Las Vegas swingers club armed with salivary testosterone test kits and, hopefully, latex gloves. They found that men who participated in sex acts over the course of the evening experienced an average testosterone boost of 72%, while those who merely watched had an average rise of 11%. Food for thought.
But on the other hand, if you happen to meet Ms or Mr Right and get into a relationship – well, good for you, but your testosterone will likely begin to decline. Should you settle down together and have a child, it will fall even further; studies have found that the more time men spend caring for young children, the lower their testosterone level can drop. It’s evolution’s way of telling you to be a good dad, says Professor Gray. ‘If you’ve got a six-month-old that you’re tending to, that might not be the time to be seeking another mate or getting in other kinds of competitive encounters.’
It’s probably also time to drop the swingers club membership and, say, join a gym. Studies have shown that taking testosterone can increase muscle size and strength – but other studies have found that strength training itself can boost testosterone levels, as Hall discovered. ‘It’s kind of a chickenand-egg thing,’ says Dr Wittert.
The equation is reversed for fat. ‘If you gain weight, it pushes testosterone down,’ Dr Wittert says. ‘If you lose weight, it goes up. And if you stay perfectly healthy, testosterone levels stay perfect.’ Studies in very healthy older men reveal no age-related decline in testosterone.
Bottom line: your testosterone level could say more about your general health than it does about your age. Many things can drive down T levels – for example, being forced to attend your sister’s baby shower. Poor sleep and lots of chronic stress can also disrupt testosterone production in the long-term, adds Peter Attia, a physician focused on longevity. Sleep and stress are the primary drivers of low testosterone, he says. Deep sleep in particular helps recharge the body’s hormonal axis, renewing its supply of good things such as testosterone and human growth hormone. ‘I need a reason before I’m going to treat someone,’ says Dr Attia. ‘I don’t just treat the [testosterone] number.
And some people with low testosterone levels might not have any symptoms. They feel just fine.’
We’ve talked about Covid stress, but stress in general can knock testosterone down, through the action of the stress hormone cortisol – which is also elevated by poor sleep hygiene.
The same goes for depression, which many men are reluctant to address.
Dr Wittert argues that it’s important to take inventory of what else might be going on before resorting to the quick fix of a T prescription. ‘It’s not a substitute for eating better… [or] for fixing your mood disorder, or finding you have sleep apnoea and getting it treated, or addressing your dyslipidemia or your lack of physical activity, or for getting enough sleep,’ he says. ‘It starts and ends with lifestyle.’
Other doctors see testosterone as a potentially useful treatment for these symptoms, even as a short-term jump-start. The average Hone patient, says the company’s medical director, Jim Staheli, is ‘a typical young guy who’s married, he has several children, is overweight, he’s stressed out of his gourd because of his job, he isn’t sleeping, he isn’t eating well – and as a result… his testosterone has plummeted’.
Not surprising. But, Dr Staheli adds, this guy is not just going to automatically get a vial of testosterone in the post next week. His treatment will depend on his blood test results– testosterone is checked twice – and a follow-up consultation with a physician who asks questions about all aspects of his life.
‘Someone who’s 35 probably isn’t going to want to be on T for the rest of his life,’ Dr Staheli says. Rather, such a patient might start off on a drug called Clomid, which stimulates the body’s own production of testosterone without impairing fertility; this is what Alam’s doctor first prescribed him.
‘We like to focus on the Clomid approach first, see if we can get the natural production up, along with lifestyle changes: diet-related, sleeping better and certainly exercise,’ says Dr Staheli. ‘If we can get their testosterone levels up enough that they become asymptomatic, then it’s a win-win.’
Still, it’s definitely worth figuring out why your testosterone is low before clicking ‘checkout’ for that online prescription.