Testosterone deficiency (hypogonadism) is a real clinical condition with real consequences. It is also widely over-diagnosed and casually treated by clinics that prescribe on the basis of symptoms alone. Both problems — undertreatment and careless treatment — cause harm.
Symptoms
- Low libido and reduced spontaneous erections
- Fatigue and reduced energy
- Loss of muscle mass and strength; increased body fat
- Depressed mood, irritability, difficulty concentrating
- Decreased bone density
- Reduced body hair; hot flashes in severe deficiency
These symptoms are non-specific — they overlap with sleep apnea, depression, thyroid disease, anemia, and simply poor sleep. That overlap is exactly why diagnosis requires laboratory confirmation, not a symptom questionnaire.
How low testosterone is properly diagnosed
- Two separate morning measurements. Testosterone follows a daily rhythm and peaks in the morning; a single afternoon draw is not adequate for diagnosis.
- Confirmed low total testosterone, with free testosterone measured when total is borderline or when binding proteins may be altered.
- LH and FSH to distinguish testicular failure from a pituitary or hypothalamic cause.
- Prolactin when levels are very low, to look for a pituitary tumor.
- Baseline hematocrit and PSA, since both must be monitored during therapy.
- Evaluation for reversible causes — obesity, obstructive sleep apnea, opioids, alcohol, and certain medications all suppress testosterone, and correcting them sometimes eliminates the need for treatment.
Before starting: fertility
This deserves emphasis because it is frequently missed. Testosterone therapy suppresses sperm production and can cause infertility, sometimes lasting well after stopping. Any man who may want children in the future should discuss this before beginning treatment. Alternatives that raise testosterone while preserving fertility — clomiphene, hCG, or aromatase inhibitors in selected cases — are available and are often the better choice.
Treatment options
| Formulation | Administration | Considerations |
|---|---|---|
| Topical gel | Daily to the skin | Steady levels; requires care to avoid transferring to a partner or child |
| Injections (cypionate/enanthate) | Weekly or biweekly, self-administered | Inexpensive and effective; levels fluctuate between doses |
| Long-acting injection (undecanoate) | Every ~10 weeks in office | Infrequent dosing; requires in-office observation after administration |
| Subcutaneous pellets | Implanted every 3–6 months | Nothing to remember; minor in-office procedure to place |
| Oral (newer formulations) | Twice daily with food | Avoids injections; requires blood pressure monitoring |
Monitoring — and why it is not optional
Testosterone therapy requires ongoing laboratory follow-up. The main issues to watch:
- Hematocrit. Testosterone stimulates red blood cell production; excessive thickening of the blood raises clotting risk and may require dose reduction, phlebotomy, or stopping treatment.
- PSA and prostate health. Monitored on a defined schedule. Current evidence does not show that therapy causes prostate cancer, but surveillance remains standard practice.
- Testosterone level. Dosing is adjusted to reach the mid-normal range — not supraphysiologic levels.
- Symptom response. If symptoms do not improve after an adequate trial at proper levels, low testosterone was probably not the cause, and continuing indefinitely is not appropriate.
Research at Tulane
Dr. Azad leads clinical research on male infertility and low testosterone, including trials evaluating new treatment options for men with low sperm count and low testosterone. Men who may qualify can ask about current studies at the time of consultation.
Common questions
How do I know if I really have low testosterone?
Diagnosis requires two separate morning blood measurements showing low levels, together with symptoms. A single test, an afternoon draw, or a symptom questionnaire alone is not sufficient. LH, FSH, and other labs help identify the underlying cause.
Does testosterone therapy cause infertility?
Yes, it can. Testosterone therapy suppresses the body's own production signals and reduces sperm production, and the effect can persist after stopping. Men who may want children should discuss this before starting. Clomiphene, hCG, or aromatase inhibitors can raise testosterone while preserving fertility in appropriate candidates.
Does testosterone therapy cause prostate cancer?
Current evidence does not show that testosterone therapy causes prostate cancer. That said, PSA and prostate health are monitored on a defined schedule during treatment, and men with known prostate cancer require individualized evaluation before therapy is considered.
Which form of testosterone is best?
There is no single best formulation — the right choice depends on your preferences and circumstances. Injections are inexpensive and effective but produce fluctuating levels; gels give steady levels but require care around skin contact with others; pellets and long-acting injections reduce how often you have to think about it.
Do I have to stay on testosterone forever?
Often yes, if the underlying cause is permanent, since levels fall again after stopping. When a reversible cause is identified and corrected — obesity, untreated sleep apnea, opioid use — testosterone may recover without long-term therapy.
Why do wellness clinics prescribe testosterone so easily?
Because it is profitable and demand is high. The risk is treating men who do not have testosterone deficiency, missing conditions like sleep apnea or depression that are causing the symptoms, skipping the fertility discussion, and failing to monitor hematocrit and PSA. Proper evaluation takes longer but avoids those problems.
What are the risks of testosterone therapy?
The main ones are increased red blood cell concentration (which raises clotting risk), suppressed fertility, acne and oily skin, breast tenderness, fluid retention, and worsening of untreated sleep apnea. Most are manageable with correct dosing and regular monitoring.
Related procedures
Discuss your options with Dr. Azad
Referrals are welcome but not required. Bring any records from prior procedures — operative notes, imaging, or urethrograms — and we will review them together.
504-988-5271Dr. Babak Azad — Reconstructive Urology, Metairie & New Orleans, LA