What You Need to Know About Testosterone Testing and Testosterone Replacement Therapy

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The number of testosterone prescriptions have tripled over the past decade, causing researchers to sound the alarm that men may be abusing the hormone

The US Food and Drug Administration (FDA)has suggested that testosterone products should carry a warning label indicating a heightened risk for blood clots

Testosterone should only be given to men with persistent symptoms and unequivocally low testosterone levels, a condition known as hypogonadism

If you’re under the age of 45 and have erectile dysfunction, it would be wise to test your testosterone between 8-11 am for the most accurate measurement, as this is when your testosterone tends to peak

If you’re older than 45 and have erectile dysfunction, you can do the test anytime before 2 pm without misleading results, as recent research shows the testosterone cycle gets blunted with age

Testosterone is on many men’s mind these days; undoubtedly due in large part to TV ads promising more pep in your step and improved sex life.

In 2012, prescription testosterone gels generated over $2 billion in US sales. Abbott Laboratories alone spent $80 million on seductive direct-to-consumer advertising for its testosterone product AndroGel that same year.

The problem is, testosterone is now being used by men who really are not good candidates for hormone replacement, and this might seriously jeopardize their health.

Earlier this summer, the US Food and Drug Administration (FDA) suggested that testosterone products should carry a warning label indicating a heightened risk for blood clots. But that’s not the only potential adverse side effect of testosterone hormone replacement.

On September 17, the FDA will hold an advisory committee meeting1, 2 to discuss the adverse cardiovascular outcomes associated with testosterone replacement, and how to manage such risks.


Many Men Are Taking Testosterone Without Evidence of Deficiency

Recent research3, 4, 5 shows that the number of testosterone prescriptions have tripled over the past decade, causing researchers to sound the alarm that men may be abusing the hormone.

According to the Endocrine Society, which is responsible for setting the clinical guidelines for testosterone replacement therapy, testosterone should only be given to men with persistent symptoms and “unequivocally low testosterone levels,” a condition known as hypogonadism.

The most common way physicians determine if you have hypogonadism is by measuring your testosterone level.

According to a 2012 study6 looking at the sensitivity and specificity of total testosterone (total T) as an indicator of biochemical hypogonadism, a serum total T level below 150 ng/dl is indicative of hypogonadism, while levels above 350 ng/dl excludes the condition in most cases.

If you fall within that range of 150-350 ng/dl, the authors advised measuring free or bioavailable T levels, which are thought to identify biochemical hypogonadism more accurately.

However, recent findings indicate that 25 percent of men given a prescription for testosterone did not have their levels tested prior to receiving a prescription, and of the remaining 75 percent, it was unclear as to how many actually had a testosterone deficiency.

In short, there appears to be large numbers of men taking testosterone that probably shouldn’t be. Using hormones as a “cure-all” is a risky proposition, especially if your problems are related to lifestyle as opposed to an actual medical condition that severely impairs your hormone production. What most men really need to properly address this issue is a lifestyle change. This will optimize their body’s natural production of testosterone and other hormones.


What’s the Best Time of Day to Test Your Testosterone Level?

When testing your testosterone level, doctors will typically recommend measuring it somewhere between 8 and 11 am, as this is when a man’s testosterone level tends to naturally peak. Levels naturally decline by about 50 percent throughout the day, but recent research shows that this levels off in older men.

The authors concluded that:7, 8

“Total testosterone in men with erectile dysfunction who are younger than 45 years should be drawn as close to 7 a.m. as possible because a statistically and clinically relevant decrease in testosterone will occur during the course of the day.

Men older than 45 years with erectile dysfunction can have total testosterone drawn at any time before 2 p.m. without misleading results.”

According to Mark Newman, President of Precision Analytical, Inc.,9 (my favorite hormone testing service, and the one I use personally) a blood test is ideal if you’re solely looking at your testosterone level at any given time of the day, but a urine test can offer testosterone levels and additional markers.

These additional markers help to uncover what is going on if the issue is related to other hormones as well. Watch the video further below for an example of the complexities that can be at play in cases where simple testosterone deficiency is not the issue. Saliva testing can also be used, but is probably the least reliable, especially for women (because levels are too low for the technology to be highly accurate).

One caveat for urine testosterone is that it is not recommended for people of Asian descent. There is a genetic variant that is common in people of Asian descent that can cause urinary testosterone to be falsely low.


Potential Side Effects of Testosterone Replacement Therapy

There’s a fair amount of controversy on the subject of testosterone replacement therapy. Some of the evidence suggests it may cause worrisome side effects (especially if you’re not actually deficient), including:

Thickening of the blood/blood clots Acne
Reduced sperm count Increased risk of heart disease
Increased risk of prostate cancer Male infertility10
Liver problems Male breast growth
Increased male pattern baldness Worsening of urinary symptoms


According to a study published in the journal PLoS ONE11 earlier this year, men aged 65 and older who took testosterone DOUBLED their risk of having a heart attack within the first three months of use, even if they did not have heart disease prior to starting the therapy. The result was similar in younger men diagnosed with heart disease.

The study was prompted by a 2010 clinical trial12 that was shut down before completion due to the increase in heart-related problems occurring in the testosterone treatment group.

Another issue complicating this subject is the fact that lab testing for patients on testosterone is not straightforward for many of the popular types of supplementation. Testosterone taken as drops, lozenges, or on the skin creates lab testing values that can be highly misleading. See the testing matrix below and the video for a practical clinical example if you are on testosterone and want to be tested while on therapy.

Why Treating Testosterone by Itself May Be Unwise

Besides these potential side effects, treating testosterone by itself may be unwise for other reasons. Additional downsides include its effects on other hormones and precursors, such as DHEA and its metabolites, dihydrotestosterone (DHT), and cortisol. DHEA is one of the most abundant precursor hormones in your body. It is crucial for the creation of vital hormones, including testosterone and other sex hormones.

Your adrenals produce both DHEA and cortisol, which is in direct competition with DHEA for production. In other words, when cortisol production is high, especially for prolonged periods of time, your adrenals can become impaired, and your DHEA production will suffer as a result. Chronic stress basically causes excessive cortisol levels and impairs DHEA production, which is why stress is another factor for low testosterone levels.

Now, if your adrenal function is off and you fail to address that first, before you start testosterone replacement therapy, it could cause loads of problems… Another problem with testosterone therapy is that your body could metabolize it to dihydrotestosterone (DHT), which can lead to an acceleration of male pattern baldness and prostatic hypertrophy.

Mark Newman provides a case scenario in the video above highlighting many of these examples in a single patient case. In that scenario, the patient had symptoms of low testosterone. When tested, his testosterone was NOT low, but he showed high cortisol and estrogen (likely the cause of some of his symptoms). Furthermore, the patient had very high DHT levels, so increasing testosterone further could put the patient at higher risk for prostate cancer.

The subject of this case study showed many concerning results (high estrogen, high “bad” estrogen metabolites, high DHT, high cortisol, low DHEAS). The good news is that almost all of the issues presented in this case could be significantly improved with fairly simple lifestyle and nutritional interventions. Somewhat blindly intervening with hormones (like testosterone) did NOT make sense in that case and likely would have exacerbated many of the problems (increasing testosterone unnecessarily would have made estrogens and DHT even higher).


More Confounding Factors: Low Libido in Men May Also Be Related to Low Estrogen

Treating low testosterone by itself may lead to more problems if you have underlying adrenal dysfunction, for example. In addition to that, other sex hormones, such as estrogen, also play a critical role in men’s health, so the heavy focus on testosterone may be inappropriate for more than one reason. One recent study13 determined that while testosterone deficiency accounted for decreases in men’s lean mass, muscle size, and strength, estrogen deficiency was the primary culprit when it came to increases in body fat. Both hormones were found to be important for male sexual function, and a deficiency in either had a negative impact on the men’s libido.

Please note that men are NOT advised to take estrogen replacement therapy, as this could cause feminization, such as enlarged breasts. As your testosterone levels rise, your body will automatically produce more estrogen, but that does not automatically imply that testosterone therapy is warranted. Again, these hormonal disruptions are typically rooted in a flawed lifestyle approach, NOT in an actual medical condition that severely impairs your body’s natural ability to produce hormones. The answer, therefore, will usually be found in lifestyle changes that will help optimize your body’s hormone production.


Unsafe Hormone Use Among Teens Is Also on the Rise

Unfortunately, the appeal of a quick fix is pervasive. Young men are also misusing other hormones, such as human growth hormone (HGH) in increasing numbers. According to one poll,14 11 percent of American teenage boys in grades 9-12 reported using synthetic HGH at least once without prescription! Nine percent of girls polled had also used it. Teenage use of synthetic HGH has more than doubled from 2012 to 2013, and the primary reason given for using HGH was to improve athletic performance and boost muscle growth.

Steroid use is also on the rise among teens. Even though HGH is a banned substance in nearly every sport, some athletes still choose to inject HGH for its performance enhancing potential. I do not recommend this, as the potential side effects can cause more long-term harm than good. Besides, taking such risks is completely unnecessary, because if you eat and exercise correctly, using high intensity interval exercises, you will naturally optimize your HGH, regardless of your age.


How to Raise Your Testosterone and HGH Levels Naturally

Personally, I do not recommend using testosterone hormone replacement unless medically warranted. Even then, if you indeed have low testosterone, I would suggest considering using trans rectal DHEA cream instead of testosterone replacement, and only for the short-term. I would even be cautious with that, and only use it with careful hormone monitoring. Remember, when taking DHEA or testosterone, both can get turned into estrogens or DHT, so comprehensive hormone profiling is beneficial to make sure the hormone isn’t causing an imbalance in the hormone being taken or a different hormone downstream.

I used small amounts of DHEA like 10-25 mg several years ago but was able to normalize my hormones with the use of high intensity exercises. So I believe most can avoid the use of DHEA or testosterone, provided they take the appropriate steps to optimize their body’s ability to manufacture these hormones. Both HGH and testosterone are boosted in response to short, intense exercise. Below is a summary and video demonstration of what a typical high-intensity Peak Fitness routine might look like.

  • Warm up for three minutes
  • Exercise as hard and fast as you can for 30 seconds. You should feel like you couldn’t possibly go on another few seconds
  • Recover at a slow to moderate pace for 90 seconds
  • Repeat the high intensity exercise and recovery 7 more times
When it comes to an exercise plan that will complement testosterone function and production, I recommend including both high-intensity interval training and strength training. When you use strength training to raise your testosterone, you’ll want to increase the weight and lower your number of reps. Focus on doing exercises that work a wider number of muscles, such as squats or dead lifts. You can take your workout to the next level by learning the principles of Super-Slow Weight Training.

Nine More Ways to Naturally Increase Your Testosterone Levels

While I believe high intensity interval training is one of the most potent ways to optimize your natural hormone production, it’s certainly not the only way. The following strategies are also known to be quite effective:

Whole body vibration training (WBVT) Besides high intensity exercise, whole body vibration training using a Power Plate can also independently increase growth hormone levels. Like high intensity exercise, WBVT also works all three types of muscle fibers, and it does so more effectively and efficiently than straight cardio or weight lifting.
You can accomplish more from 15 minutes on the Power Plate than from an hour of traditional strength training. By stimulating your white muscle fiber, the Power Plate kick-starts your pituitary gland into making more growth hormone, which helps you build lean body mass and burn fat.
Lose excess weight by optimizing your diet If you’re overweight, shedding the excess pounds may increase your testosterone levels, according to recent research.15 Testosterone levels decrease after you eat sugar, which is likely because the sugar leads to a high insulin level, which is another factor leading to low testosterone.
The most efficient way to shed excess weight is to strictly limit the amount of sugar/fructose, grains (including organic grains) and milk (even raw) in your diet. (Milk has a sugar called lactose, which has been shown to increase insulin resistance, so it will be wise to avoid it if you are seeking to lose weight.)
Replace these dietary troublemakers with vegetables and healthy fats, such as organic pastured egg yolks, avocado, coconut oil, butter made from raw grass-fed organic milk, and nuts like almonds and pecans.
Saturated fats are essential for building testosterone. Research shows that a diet with less than 40 percent of energy as fat (and that mainly from animal sources, i.e. saturated) leads to a decrease in testosterone levels.16 My personal diet is about 70-80 percent healthy fat, and other experts agree that the ideal diet includes somewhere between 50-85 percent fat. I’ve detailed a step-by-step guide to this type of healthy eating program in my comprehensive nutrition plan, and I urge you to consult this guide if you are trying to lose weight.
Intermittent fasting Another effective strategy for enhancing both testosterone and HGH release is intermittent fasting. It helps boost testosterone by improving the expression of satiety hormones, like insulin, leptin, adiponectin, glucacgon-like peptide-1 (GLP-1), cholecystokinin (CKK), and melanocortins, which are linked to healthy testosterone function, increased libido, and the prevention of age-induced testosterone decline.
Consume enough, but not too much, zinc Zinc is important for testosterone production, and supplementing your diet for as little as six weeks has been shown to cause a marked improvement in testosterone among men with low levels.17 Likewise, research has shown that restricting dietary sources of zinc leads to a significant decrease in testosterone, while zinc supplementation increases it19 — and even protects men from exercised-induced reductions in testosterone levels.18
Along with protein-rich foods like meats and fish, other good dietary sources of zinc include raw milk, raw cheese, beans, and yogurt or kefir made from raw milk. If you decide to use a zinc supplement, stick to a dosage of less than 40 mg a day, as this is the recommended adult upper limit. Taking too much zinc can interfere with your body’s ability to absorb other minerals, especially copper, and may cause nausea as a side effect.
Optimize your vitamin D level Vitamin D, a steroid hormone, increases levels of testosterone, which may help boost libido. In one study,19 overweight men who were given vitamin D supplements had a significant increase in testosterone levels after one year.
To get your levels into the healthy range of 50-70 ng/ml, appropriate sun exposure is your best bet. If sun exposure is not an option, a safe tanning bed (with electronic ballasts rather than magnetic ballasts, to avoid unnecessary exposure to EMF fields) can be used.
As a last resort, a vitamin D3 supplement can be taken, but research suggests the average adult needs to take 8,000 IUs of vitamin D per day in order to elevate their levels above 40 ng/ml, which is the absolute minimum for disease prevention. Furthermore, if you opt for a supplement, you also need to make sure you’re getting sufficient amounts of vitamin K2, as these two nutrients work together.
Ashwagandha This perennial herb is known as an adaptogen, which can help boost stamina, endurance, and sexual energy. Research published in 201020 found that men taking the herb Ashwagandha experienced a significant increase in testosterone levels. It also promotes overall immune function, and can help increase your resistance to occasional stress.21
While some adaptogens are stimulants in disguise, this is not the case with Ashwagandha. It can give your morning exercise routine a boost, and when taken prior to bed, it can help you get a good night’s sleep as well. I recommend using only 100% organic Ashwagandha root, free of fillers, additives, and excipients, to ensure quality.
Saw palmetto Another supplement that can address certain symptoms commonly associated with low testosterone is saw palmetto. This herb may also help increase testosterone levels by inhibiting up-conversion to dihydrotestosterone.22 There are about 100 clinical studies on the benefits of saw palmetto, one of them being a contributed to decreased prostate cancer risk.
When choosing a saw palmetto supplement, you should be wary of the brand, as there are those that use an inactive form of the plant. Look for an organic supercritical CO2 extract of saw palmetto oil, which is dark green in color. Since saw palmetto is a fat-soluble supplement, taking it with eggs will enhance the absorption of its nutrients.
Astaxanthin (alone or in combination with saw palmetto) There is also solid research indicating that if you take astaxanthin in combination with saw palmetto, you may experience significant synergistic benefits. A 2009 study published in the Journal of the International Society of Sports Nutrition found that an optimal dose of saw palmetto and astaxanthin decreased both DHT and estrogen while simultaneously increasing testosterone.23
Have effective strategies to address stress During stress, your body releases high levels of the stress hormone cortisol, which blocks the effects of testosterone.24 Chronic stress, and subsequently elevated levels of cortisol, could mean that testosterone’s effects are blocked in the long term, which is what you want to avoid.
My favorite overall tool to manage stress is EFT (Emotional Freedom Technique). It’s a handy, free tool for unloading emotional baggage quickly and painlessly. Other common stress-reduction tools with a high success rate include prayer, meditation, laughter and yoga, for example. For more tips, see my article “10 Simple Steps to Help De-Stress.”

For Most Men, Testosterone Replacement Is Unnecessary

I know first-hand that low testosterone is not an automatic outcome of aging, provided you incorporate certain lifestyle strategies that can naturally boost your testosterone levels. High intensity interval exercises get top billing among them, but your diet is also an important factor, and certain supplements can be helpful adjuncts.

These strategies are part and parcel of an overall healthy lifestyle, so they also automatically reduce your risk of most chronic disease, including heart disease, which just so happens to be an adverse side effect of testosterone replacement therapy. For most men, the risks simply outweigh the benefits of testosterone therapy, and you’re far more likely to achieve optimal health by addressing lifestyle factors that brought on the symptoms of hormone dysfunction in the first place.

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