Episode Highlights
The Natural Decline
Why testosterone falls with age and how SHBG accelerates the loss of free, active hormone
What Testosterone Does
Messenger, anabolic driver, and precursor to DHT and estradiol — the balance that shapes male vitality
Signs of Low T
From libido and mood to bone density, metabolism, anemia, and body composition
The Vicious Cycle
How belly fat, estrogen conversion, and declining muscle mass reinforce low testosterone
Lifestyle Levers
Resistance training, sleep, nutrition, and micronutrients that boost testosterone naturally
The Historical Story
From Brown-Séquard’s experiments to Nobel Prize–winning synthesis and modern TRT
Today’s Options
Injections, creams, enclomiphene, HCG, and when each approach makes sense
Side Effects & Safety
Hematocrit, blood pressure, fertility, prostate, and why super-physiological dosing backfires
Making the Choice
When older men should consider TRT — and why younger men should focus on lifestyle first
Show Notes
Testosterone levels decline with age, leaving many men with less energy, lower libido, more body fat, and fading strength. By age 60, one in five men has hypogonadism. By 80, it’s half. Should men simply accept this decline — or use modern medicine to restore testosterone to youthful levels?
In this episode of The Dr. Kumar Discovery Podcast, Dr. Ravi Kumar breaks down the full story of testosterone: how it works, why it declines, and what happens when levels drop too low. You’ll hear about the natural lifestyle levers that raise testosterone, the history of testosterone replacement therapy, and the modern options available today — from injections to enclomiphene.
In this episode, you will discover:
- Normal youthful levels — total testosterone, free testosterone, and SHBG in young men
- Biological roles — muscle, bone, red blood cells, mood, metabolism, libido, and fertility
- The decline — 1–2% yearly drop in testosterone, plus rising SHBG binding more hormone
- Consequences of low T — reduced libido, loss of lean mass, more fat, depression, anemia, weaker bones
- The vicious cycle — belly fat converts testosterone to estrogen, fueling further decline
- Natural optimization — lifting, sleep, nutrition, and micronutrients like zinc, magnesium, boron, vitamin D
- Replacement options — testosterone injections, gels, enclomiphene, HCG, and when each is appropriate
- Risks and side effects — hematocrit rise, blood pressure, prostate, fertility suppression, and acne
- Super-physiological dosing — why extreme “steroid” use harms the heart, brain, fertility, and virility itself
- The decision — when older men should consider TRT, and why younger men should protect natural biology
If you’ve ever wondered whether testosterone therapy could restore strength, vitality, and energy — or if you simply want to understand how male hormones shape health — this episode is essential listening.
For more health insights, subscribe to The Dr. Kumar Discovery Podcast on any major platform.
Cheers!
Transcript
[00:00 –> 00:24] On this episode of the doctor Kumar discovery. Should we replace an older man’s hormones with those of a younger man? As men age, oral testosterone declines by about 1.3% per year starting in the thirties. At the same time, SHBG rises about 2% per year. That combination means the pool of free usable testosterone shrinks by two to 3% per year.
[00:24 –> 00:48] Now you might think, wait, estrogen’s a woman’s hormone. But in men, estradiol is critical. It maintains bone, brain function, fat distribution, and even libido. Without enough estradiol, a man’s sex drive drops off dramatically. Think of a young man in his twenties who might want sex with his partner multiple times a day compared to a man in his sixties who’s content with once a week or less frequently.
[00:48 –> 01:08] That’s the difference testosterone makes. So as belly fat builds, more of your already declining testosterone gets converted to estrogen. The result is a self reinforcing loop of lower testosterone, higher estrogen, more fat, and worsening hypogonadism. My name is Doctor. Ravi Kumar.
[01:08 –> 01:36] I’m a neurosurgeon in search of the causes of human illness and the solutions that help us heal and thrive. I want you to join me on a journey of discovery as I turn over every stone in search of the roots of disease and the mysteries of our resilience. The human body is a mysterious and miraculous machine with an amazing ability to self heal. Let us question everything and discover our true potentials. Welcome to the Doctor.
[01:36 –> 01:44] Kumar discovery. Welcome to the Doctor. Kumar discovery podcast. My name is Doctor. Ravi Kumar.
[01:44 –> 02:15] I’m a board certified neurosurgeon and assistant professor at UNC. Today, we’re gonna talk about male hormone optimization. And that conversation largely centers around testosterone, the primary sex hormone that makes a man a man. The question I wanna explore is this, should we restore an older man’s hormones to the levels of a younger man? Because when you look at youthful men in their late teens and early twenties, they tend to be leaner, stronger, with more energy.
[02:15 –> 02:38] Their moods are steadier. Their libido is stronger, and they often have a more vigorous drive in life. But as men age, those qualities begin to fade, and much of that has to do with a steady decline of testosterone. If we look at testosterone levels across the decades, the numbers are striking. By the time a man reaches his sixties, about one in five is already hypogonadal.
[02:38 –> 02:58] In his seventies, it’s closer to one in three. And by the time you get to your eighties, half of all men fall into that category. Now what does hypogonadal mean? Well, it doesn’t just mean slightly low testosterone. It means insufficient testosterone so low that the body can’t maintain its male secondary sex characteristics.
[02:58 –> 03:28] In other words, it’s an actual hormone deficiency, and this decline is real and well documented, which brings us back to our original question. Do we accept it as just another part of aging? Letting the male vigor dissipate as hormones fall, or do we take advantage of the fact that we now have technology to restore hormones to youthful levels safely and effectively? That’s the question I wanna answer today. And just to be clear, I’m not talking about pushing testosterone to extreme bodybuilder levels.
[03:28 –> 03:48] I’m talking about restoring normal, healthy ranges, the same ranges that keep young men in their prime, but in older men. So before we jump in, a quick disclaimer. I’m a medical doctor, but I’m not your doctor. This show is for informational purposes only. It’s not intended to diagnose or treat any medical conditions.
[03:48 –> 04:07] What I share here is meant to empower you with clear, unbiased information that helps you think more clearly about your health. You can take that knowledge and work with your own health care provider to figure out the right solutions for you. And just so it’s clear, this podcast is separate from my role as assistant professor at UNC. Alright. Let’s get back to it.
[04:07 –> 04:27] As we said, there’s a natural decline in testosterone across the life stages of a man. To really understand this, we need to be familiar with three different lab values. Total testosterone, free testosterone, and sex hormone binding globulin. It’s often called SHBG. Total testosterone is the overall amount of testosterone circulating in your blood stream.
[04:28 –> 04:48] Some of it’s bound to proteins, and some of it’s free. Free testosterone is the unbound portion, the fraction that can actually enter cells and do biological work. Then we have SHBG. This is one of the proteins that binds testosterone and keeps it from being biologically active. Think of it as a breaking system, making sure testosterone doesn’t run too high.
[04:48 –> 05:29] Now let’s set a baseline by looking at young men, those in their late teens to late thirties. Large studies show that median total testosterone in men aged 19 to 39 is around 531 nanograms per deciliter. That’s a good benchmark, and I would say the healthiest range in this cohort is anywhere from the fiftieth to the ninetieth percentile, which puts us at around 500 to 900 nanograms per deciliter. In young men, the median free testosterone is around a 190 picograms per milliliter, with the fiftieth to ninetieth percentile ranging up to 274 picograms per milliliter. And really, this free testosterone is what counts.
[05:29 –> 05:50] Your doctor may check your total testosterone, but it’s the free fraction that truly drives male sex characteristics. And we also have to talk about sex hormone binding globulin, SHBG. Remember, it’s the protein that binds up testosterone, preventing it from being active. And here’s the dynamic. As men age, total testosterone declines by about 1.3% per year starting in the thirties.
[05:51 –> 06:17] At the same time, SHBG rises about 2% per year. That combination means the pool of free usable testosterone shrinks by two to 3% per year. So what you end up with is a double hit. Less total testosterone in circulation and more protein binding it up. Over time, that creates a steady age related hormonal senescence, a gradual fading of a hormone that drives so many traits of male vitality.
[06:18 –> 06:50] So to sum it up, what’s normal in a healthy young male? Total testosterone in the fiftieth to ninetieth percentile typically ranges between 500 to 900 nanograms per milliliter. Free testosterone falls between a hundred and ninety and two hundred and seventy four picograms per milliliter. An SHBG usually sits in the twenty five to thirty five nanomole per liter range, the sweet spot where optimal free testosterone can still circulate and do its work. Now that we know the normal levels in a younger man, let’s define what testosterone actually does.
[06:50 –> 07:17] We all know it’s a male hormone, but how is it really working inside the body? Testosterone is essentially a messenger. It’s a fat soluble compound made from cholesterol, the backbone of every steroid hormone, and it’s produced in the testes, and then used both locally and throughout the body. Once in circulation, testosterone slips into cells and binds to something called androgen receptor, which sits inside the nucleus. Think of the receptor as a switch.
[07:17 –> 07:44] When testosterone flips it on, specific genes are activated to build and repair. That’s why we call testosterone and its derivatives anabolic steroids. Anabolism means building up, muscle, bone, red blood cells, tissue. Catabolism is the opposite, the breaking down and recycling of the body. Testosterone pushes the body towards anabolism, preparing a man for strength, vitality, and ultimately, reproductive success.
[07:44 –> 08:11] Testosterone also converts into other important hormones. Through the enzyme five alpha reductase, it becomes dihydrotestosterone or DHT, which acts on the prostate, skin, and hair follicles. DHT is actually a stronger androgen than testosterone itself. Another pathway is aromatization, where testosterone is converted by the enzyme aromatase into estradiol, a form of estrogen. Now you might think, wait, estrogen’s a woman’s hormone.
[08:11 –> 08:35] But in men, estradiol is critical. It maintains bone, brain function, fat distribution, and even libido. Without enough estradiol, a man’s sex drive drops off dramatically. So testosterone, DHT, and estradiol form an ecosystem. They sit under the same hormonal umbrella and need to be in balance, something that usually holds true in younger men.
[08:35 –> 09:02] So now that we know testosterone declines with age, we know the healthy levels of a younger man, and we know how testosterone works biochemically, the next question is, so what? Maybe this is just part of aging and maybe we should just let it happen. So to answer that question, we have to first know what really happens to a man as his testosterone levels decline. The first and strongest signal is usually sexual desire. Libido drops off.
[09:02 –> 09:20] Men with low testosterone simply want sex less. It’s often the first flag. Think of a young man in his twenties who might want sex with his partner multiple times a day compared to a man in his sixties who’s content with once a week or less frequently. That’s the difference testosterone makes. And this isn’t just anecdote.
[09:20 –> 09:47] In the TRAVERSE trial, the largest clinical trial on testosterone replacement in men, a sub study looked at sexual activity. They found that men on testosterone therapy averaged about half a sexual act more per day. In real terms, that’s roughly one additional sexual encounter every two days. A huge change, especially for older men who might only be having sex weekly, monthly, or even less. The next place testosterone decline shows up is in body composition.
[09:47 –> 10:12] Testosterone preserves lean body mass. It keeps body fat low and supports strength. It’s why young men often look muscular and lean without much effort. With age, as testosterone falls, muscle mass declines, body fat increases, and strength fades. In clinical studies, intramuscular testosterone replacement increased lean muscle mass by about 5.7%.
[10:12 –> 10:32] That’s a substantial improvement, and that’s without even factoring in exercise. Add in physical training, and the effects amplify dramatically. And here’s why it becomes a vicious cycle when you have low testosterone. With the less muscle, you burn fewer calories and become less insulin sensitive. That means glucose isn’t handled as well, and it gets stored as belly fat.
[10:33 –> 10:57] And belly fat isn’t just passive storage. It’s hormonally active. Fat tissue has high aromatase activity, which converts testosterone into estradiol. So as belly fat builds, more of your already declining testosterone gets converted to estrogen. That shift leads to more fat accumulation, and in some men, even gynecomastia, which is male breast tissue.
[10:57 –> 11:30] The result is a self reinforcing loop of lower testosterone, higher estrogen, more fat, and worsening hypogonadism. Breaking that cycle naturally is difficult, and it’s part of why restoring youthful hormone levels could be super powerful for some men. Testosterone also influences mood and mental health. A meta analysis of 27 randomized controlled trials found that men with low testosterone who replaced it had a measurable reduction in depressive symptoms. The effect wasn’t huge, but it was significant.
[11:30 –> 12:00] And if you think about it, there’s a vigor, a mental energy you see in younger men that often fades with age. Low bone mineral density is another problem we usually don’t associate with men. Testosterone along with its conversion to estradiol helps maintain bone density. As testosterone declines, osteoporosis risk rises. Studies show that testosterone replacement increases bone mineral density in the spine and the hips and even strengthens estimated bone quality within a year of starting it.
[12:00 –> 12:27] Anemia is another underappreciated consequence. Normally, men maintain higher hemoglobin and hematocrit than women, partly due to testosterone’s anabolic signals, which tell the bone marrow to make more red blood cells. When testosterone falls, anemia can develop. Replacement therapy has been shown to correct this, raising hemoglobin levels, which improves oxygen delivery and energy. Finally, testosterone has an important link to metabolism.
[12:27 –> 12:54] One measure of insulin sensitivity called HOMA IR improves by about fifteen percent in men on testosterone replacement therapy. That’s significant for anyone struggling with metabolic syndrome. By adding muscle mass, the body demands more glucose, which improves insulin sensitivity and reduces resistance. So when testosterone declines, it’s not just libido that gets lost. It’s body composition, mood, bone, blood, metabolism.
[12:54 –> 13:32] And when you restore it, those systems respond and recover. So at this point, we’ve looked at how testosterone changes across a man’s life, what it does in the body, what healthy levels look like in a young man, and what happens when levels fall too low. The next question I like to ask when I’m thinking through human biology is this. What would testosterone look like in people living outside the modern world? Because when you study traditional cultures, you get a glimpse of what hormone levels might be if they weren’t influenced by the processed diets, sedentary lifestyles, and stressors of modern life, the kind of stuff that we experience every day.
[13:32 –> 14:01] One of the most interesting groups studied are the Shimane, a subsistence population in Bolivia. Researchers found that during activities like hunting, working, or even competitive play, these men experienced large testosterone surges, spikes of about 30% that held steady for a period of time. Yet, when at rest, their baseline levels were actually lower than men in the modern world. And here’s the fascinating part. Despite lower resting levels, they don’t show signs of insulin resistance.
[14:01 –> 14:39] They’re lean, strong, virile, and reproductively healthy. They’re thriving in a natural environment with hormones that match their way of life. Why would this happen? The thinking is that high activity, high pathogen environments like the environment they live in, it’s more efficient to conserve energy for fighting infections and surviving lean times rather than maintaining a large metabolically expensive, anabolically dominant body. Instead, their biology favors a smaller, more efficient baseline with the ability to rapidly ramp up testosterone when needed, whether that’s for a hunt, a fight, or physically demanding work.
[14:39 –> 15:11] What’s also striking is that this ability to surge testosterone was seen in men of all ages, from teenagers to men in their eighties. That suggests the capacity for rapid hormonal response is more important for survival than just having a high baseline all the time. To me, this shows that while basal testosterone matters, these periodic bursts tied to physical activity may be just as critical. We’ll come back to that idea later, but it underscores how activity shapes hormonal health. Now of course, these studies don’t capture everything.
[15:11 –> 15:43] They don’t account for modern concerns like body image, confidence, or social dynamics, which play a big role in our culture, but are very different from what they’re experiencing in the rainforest. Still, from an evolutionary perspective, they give us valuable clues about how flexible and how activity driven the male hormone system really is. Another angle I like to explore is the historical perspective. What did people do in the past, and how did they approach the problem of declining testosterone? If you look back, even in ancient times, castration was common.
[15:43 –> 16:19] Men were often castrated for social roles, for subservience, or because society believed certain positions were better filled by castrated men. The testicles dangling outside the body were unfortunately easy to remove without advanced surgery. And once removed, the effects were obvious. Higher pitched voices, loss of body and facial hair, weaker bones with kyphotic spines, decrease in muscle mass, it became very clear very early that those two small organs hanging between the man’s legs were responsible for a man’s vitality and sexual characteristics. Fast forward to the late eighteen hundreds.
[16:19 –> 17:03] Charles Edouard Brown Sicard, a famous French physiologist in his late seventies, became fascinated with the link between testes and vitality. Likely feeling the effects of aging himself, he began experimenting. In one of the most famous cases of self experimentation, he injected himself with a mixture of blood from the testicular veins, semen, and extracts from dog and guinea pig testes. When he presented his results to the Society of Biology in Paris in 1889, he claimed striking improvements, renewed physical vigor, sharper mental clarity, relief of constipation, and even a return of what he called fecundity of spirit. In short, he felt younger, stronger, and more alive.
[17:03 –> 17:20] Now many believe his results were placebo, and the scientific community largely dismissed his claims. But it’s almost certain he was getting at least some trace amounts of testosterone from those extracts. Was it enough to restore youthful levels? Probably not. But was it enough for him to feel something?
[17:21 –> 17:42] Possibly. Either way, his claim lit a fire. His experiments set off a craze for what became known as organotherapy, the idea that eating or injecting animal organs could restore youth. The practice spread quickly even though the results were inconsistent. Still, Brown Sicard had made one point impossible to ignore.
[17:42 –> 18:13] The testes held a powerful influence over male vitality, and the world was now paying attention to it. By the nineteen thirties, the modern pharmaceutical era took over. Scientists crystallized testosterone from old testes, officially naming it testosterone. Soon after, Adolf Boutinand and Leopold Rusica synthesized it in the lab from plant sterols. They earned the Nobel Prize for their discovery, though Boutinand was forced to reject it at the time by Nazi Germany and only received his medal after the war.
[18:13 –> 18:44] The first usable form for therapy was testosterone propionate, introduced in 1937. It was short acting leading to peaks and valleys that made consistent replacement difficult. In the nineteen fifties, testosterone enanthate arrived, offering a longer half life and steadier levels. Very quickly, athletes began experimenting with testosterone and related androgens. And by the late nineteen fifties, methandrostinolone, also called dianobol, was developed, fueling the performance enhancement movement.
[18:44 –> 19:18] Of course, misuse followed with bodybuilders pushing doses to extreme levels. But the true breakthrough was this. For the first time, men with age related hypogonadism could be restored to normal physiological levels of testosterone. Declining testosterone was now a treatable problem. And today, because of those early experiments, both the crude injections by Brown Sicard and the refined chemistry of the twentieth century, we have safe, effective, and widely available ways to restore testosterone to healthy ranges that keep men vital and strong.
[19:18 –> 19:42] Okay. So we’ve covered how testosterone naturally declines in men, and we’ve looked at the history of testosterone replacement through both societal pushes and pharmaceutical advances. But before we talk about how this applies to us today, we need to ask one more important question. Beyond natural aging, are there factors in modern life that also push testosterone down? And the answer is resoundingly yes.
[19:42 –> 20:11] One of the biggest culprits is cortisol. We live in a high stress world where success often means pushing ourselves beyond what physiology can comfortably handle. That stress drives prolonged elevations in cortisol, and cortisol is a potent suppressor of testosterone production in the testes. In fact, studies show that acute spikes in cortisol can suppress testosterone within hours. And if cortisol stays high chronically, the suppression becomes long term.
[20:11 –> 20:33] There’s a seesaw effect here. When cortisol goes up, testosterone goes down. And when testosterone is in a healthy range, your cortisol release during stressful situations is tempered. So if testosterone is low, men actually feel stress more acutely because they don’t have the hormonal buffer that normally blunts cortisol. Sleep is another huge factor.
[20:33 –> 20:59] Chronic sleep problems are everywhere in our society. And when sleep quality or quantity drops, testosterone follows. Just one week of sleeping five hours per night has been shown to cut daytime testosterone by 10 to 15% in healthy young men. Add obstructive sleep apnea into the mix, something many people have but don’t know about, and the entire testosterone axis sputters. There’s also an important caveat here.
[20:59 –> 21:27] Untreated sleep apnea can actually get worse on testosterone replacement therapy, so it’s something that must be screened for before starting testosterone. Obesity and metabolic syndrome are also major drivers. Fat mass, especially visceral fat, which is around your organs, is one of the quietest but strongest testosterone suppressors. As soon as a man starts losing belly fat, his testosterone access often wakes up. Bariatric surgery studies show this clearly.
[21:27 –> 21:48] As patients lose weight, testosterone normalizes. Medications are another piece of the picture. Opioids are the most notorious. About sixty three percent of men on chronic opioids are hypogonadal. Opioids suppress the hypothalamus, lowering gonadotropin releasing hormone, which then reduces luteinizing hormone and testicular testosterone production.
[21:48 –> 22:18] Other drugs can also blunt testosterone, including glucocorticoids, ketoconazole, spironolactone, cemetidine, certain antipsychotics, and, of course, heavy alcohol consumption. Alcohol is essentially a fungal drug, and in excess, it consistently lowers testosterone, often leading to gynecomastia, which is enlarged breasts in a man, and weight gain. Micronutrient deficiencies are another modern problem. Zinc deficiency is widespread. About two billion people worldwide are affected.
[22:18 –> 22:46] Restricting zinc for just twenty weeks can crater testosterone, while repletion doubles testosterone levels in deficient men. Magnesium also plays a role. Randomized controlled trials show that supplementation increased both total and free testosterone. And boron, though rarely discussed, is fascinating. In one clinical trial, ten milligrams of boron per day raised testosterone, lowered SHBG, and slightly reduced estradiol.
[22:46 –> 23:14] And then there’s vitamin d, which is essential for hormonal health. In overweight men, vitamin d supplementation significantly increased both total and free testosterone. Finally, overtraining is another hidden cause. Chronic endurance athletes often have persistently low testosterone because of extreme stress and energy deficiency. Their bodies simply don’t have enough resources to support normal hormone production, and that shows up as low testosterone in men.
[23:14 –> 23:50] So when you put it all together, modern life compounds the natural decline of testosterone. Stress, poor sleep, excess weight, medications, alcohol, nutrient deficiencies, and overtraining all push levels lower. The good news is that many of these are low hanging fruit. Reduce stress, prioritize seven to eight hours of sleep, get sleep apnea under control, lose five to 10% body weight if you’re overweight, replete deficiencies like zinc, magnesium, boron, or vitamin d, and avoid drugs and alcohol that directly suppress testosterone. These are all easy levers to push, and they’re things that you should do if they’re present in your life.
[23:50 –> 24:12] So now that we’ve talked about the factors that drag testosterone down, let’s flip it around. What about the things that can actually increase testosterone naturally? Because there are levers we can pull, things that fit with our biology and promote a more anabolic state in a man. The first and most reliable is resistance training. Lifting weights gives your testosterone system a real push.
[24:12 –> 24:40] After heavy lifting, testosterone rises 20 to 25% in the immediate post workout phase. Now this doesn’t necessarily raise your resting testosterone levels, but it’s very much like what we saw in the Shimani studies. Their resting levels were lower, but activity produced big bursts in testosterone. And those bursts mattered. They translated into more lean mass, less fat mass, and greater strength, all signs of a hormonally healthy male.
[24:40 –> 24:57] So how should you train? The research suggests lifting three to four times per week using heavy weights, higher volume sets, and short rest periods. But you also need to fuel your body. Anabolism requires energy. If you are in a calorie deficit, you won’t see the same hormonal responses.
[24:57 –> 25:13] Sleep is another huge lever we can pull. We know that one week of five hours per night can cut testosterone 10 to 15% in healthy young men. And if you add untreated sleep apnea into the mix, it’s even worse. Diet is critical too. Remember, testosterone is made from cholesterol.
[25:13 –> 25:46] If you don’t eat enough fat, you don’t give your body the building blocks it needs. For decades, we were told to fear fat, but fat is essential for hormones. A clinical study compared a low fat, high fiber diet with a high fat, low fiber diet. After ten weeks, the high fat group had testosterone levels that were 13 to 15% higher. And when the diets were crossed over, meaning those on the low fat diet went to the high fat diet, and those on the high fat diet started eating the low fat diet, the effect repeated equally.
[25:46 –> 26:15] There is very little doubt that higher fat diets support higher testosterone levels. The type of fat matters too. Saturated fat is probably the safest bet because it raises cholesterol, which is the backbone for steroid production, and it does not oxidize in the body. Polyunsaturated fats, especially seed oils, are more unstable and prone to oxidation, and may nudge testosterone down. The evidence is mixed, but it’s suggestive that PUFAs are the less desirable fat for hormone production.
[26:15 –> 26:44] Overall, aiming for about 40% of calories from fat is a good target with an emphasis on quality sources. Protein is also essential. At about 1.5 to two grams per kilogram of lean body weight, you give your body the building blocks it needs to stay anabolic. Beyond diet and lifestyle, certain supplements have also shown promising clinical trials. Ashwagandha, an Ayurvedic herb, has been shown to raise testosterone, increase lean muscle, and improve libido compared to placebos.
[26:44 –> 27:20] Tongat Ali also has been supported by meta analysis showing a significant increase in testosterone. Another one is shilajit, a mineral resin that’s found in the Himalayas, and it increased testosterone and DHEA in a randomized trial using two hundred and fifty milligrams twice daily for ninety days. Fenugreek is another one, which has mixed data honestly, but some studies show it boosts free and total testosterone and improves libido. And the last one I’ll mention is Phedogia Agrestis, which honestly gets a lot of attention in popular media. And the problem is there are no human studies, only rat studies showing some hormonal effects.
[27:20 –> 27:35] On top of that, there are safety concerns about potential organ toxicity. So despite the hype, this is not one I recommend. There are much safer, proven ways to support testosterone naturally. Okay. So we covered diet, lifestyle, and supplements that can support testosterone.
[27:35 –> 27:56] For many men, those changes alone are enough to bring levels back in the healthy range, And that should always be the first approach. Optimize lifestyle, fix deficiencies, and see where you land. But sometimes, the hole is too deep. If you’re already hypogonadal, medication may be the only way out. And that takes us into the realm of testosterone replacement therapy.
[27:56 –> 28:22] The most common form is testosterone siponate, an injectable testosterone ester. Once injected into the muscle or the subcutaneous tissue, it forms a depot that slowly releases over time. The goal is steady physiological levels, not peaks and crashes. In the past, men were dosed every two weeks, which led to huge spikes and deep troughs. Today, smaller, more frequent injections are preferred to smooth out the curve.
[28:22 –> 28:51] Most men start around one hundred milligrams weekly. I often recommend dividing that weekly dose in half and injecting twice weekly. For example, if you’re on a hundred milligrams weekly of testosterone cypionate, then inject fifty milligrams on Monday and fifty milligrams on Thursday. I usually recommend the subcutaneous route rather than intramuscular. It’s less painful, easier to administer, and tends to produce steadier levels with slightly lower risk of side effects like elevated hematocrit or excessive aromatization.
[28:51 –> 29:13] The pros of injectable testosterone are strong. It reliably improves libido, body composition, and energy. It’s also inexpensive per milligram and easy to titrate. The cons are that it involves needles, disposal, travel hassles, and it can raise hematocrit or blood pressure in some men. For those who dislike injections, there are topical creams and gels.
[29:13 –> 29:33] These are applied to the skin, usually the shoulders or upper arms, each morning. It’s allowed to dry first before getting dressed. The main risk is accidental transfer to partners or children, which can cause androgenic effects. So treated skin should always be covered. The benefit is stable daily levels and a lower risk of elevated hematocrit compared to injections.
[29:34 –> 30:06] And here I would say that one thing that’s important to note is that when you take testosterone exogenously, your brain senses rising estrogen from aromatization and shuts down gonadotropin releasing hormone, then LH, and finally testicular testosterone and sperm production. In other words, your testicles stop working. This leads to infertility while on therapy in the often smaller testicular size. The effect is reversible, but it’s something every man should know before starting. For men who want to preserve fertility, there are alternatives.
[30:06 –> 30:41] Enclomiphene is a SERM, which stands for selective estrogen receptor modulator, and this blocks estrogen’s negative feedback at the hypothalamus in the brain. This drives gonadotropin releasing hormone, luteinizing hormone, and ultimately testicular testosterone production. It’s taken orally, which is one of its big benefits, usually starting at twelve point five milligrams per day and sometimes titrating up to twenty five milligrams. It’s effective, preserves fertility, and has few side effects. The caveat is that enclomiphene isn’t FDA approved for this indication, though it’s widely prescribed through compound pharmacies.
[30:41 –> 31:09] There’s also clomiphene, which contains both enclomiphene and zuclomiphene. Enclomiphene is the active isomer with strong testosterone boosting effects, but zuclomiphene lingers for weeks and has estrogenic activity, which can cause side effects. For that reason, I recommend enclomiphene over clomiphene. Another option is hCG or human chorionic gonadotropin. HCG mimics luteinizing hormone and goes straight to the testes to stimulate testosterone and sperm production.
[31:09 –> 31:36] It works, but it requires injections and is very expensive. So it’s usually reserved for specific cases with guidance from an endocrinologist. There are other emerging options, intranasal testosterone, long acting injectables that last up to ten weeks, pellets, but none are as well established as injections, gels, or inclomiphene. And one last category to mention here are aromatase inhibitors, like anastrozole. These block the conversion of testosterone to estrogen.
[31:36 –> 32:07] They can be useful if estrogen side effects develop. Things like gynecomastia, which is enlarged breasts in a man, nipple tenderness, emotional swings, or loss of libido. But estrogen is vital for male health. Too little estrogen harms libido, cardiovascular health, brain function, so aromatase inhibitors should only be used when both symptoms and labs point to excess estrogen, and even then at very low doses, such as a quarter or a half a milligram once per week. So those are the main options for testosterone replacement.
[32:07 –> 32:25] Injections remain the gold standard for effectiveness. Creams offer convenience with fewer red blood cell complications. And then clomiphene or hCG are good alternatives when fertility needs to be preserved. So what about side effects? We’ve talked a lot about the benefits of testosterone replacement, but what are the potential downsides?
[32:25 –> 32:54] One of the main issues is an increase in hemoglobin and hematocrit. Testosterone stimulates erythropoietin, the same hormone that cyclists have famously used to boost their red blood cell counts. More red blood cells means more oxygen delivery and better cycling performance. But in the setting of testosterone replacement therapy, if hematocrit gets too high, the blood becomes thicker and more prone to clotting. In that case, phlebotomy, which is a simple blood draw, may be needed to reduce the risk of vascular complications.
[32:54 –> 33:21] One way to minimize this risk is to split injections into smaller, more frequent doses, which smooths out the peaks and reduces your chance of stimulating erythropoietin. Blood pressure is another thing to monitor. Studies show that testosterone therapy raises systolic blood pressure by 3.9 millimeters of mercury and diastolic blood pressure by 1.5 millimeters of mercury. Not dramatic, but it’s worth keeping an eye on. And what about the heart?
[33:21 –> 33:53] The largest study to date, the TRAVERSE trial, followed over five thousand men with hypogonadism and cardiovascular risk. The trial found no increase in major cardiac events like heart attacks or strokes with testosterone therapy. There were slightly higher rates of atrial fibrillation, pulmonary embolism, acute kidney injury, all likely related to changes in blood thickness and hemodynamics, but the risks were relatively low. Prostate health also needs attention. Because testosterone converts to dihydrotestosterone, it can stimulate prostate growth and nudge PSA levels upward.
[33:53 –> 34:18] But importantly, studies have not shown an increased risk of high grade prostate cancer compared to placebo. Still, PSA, prostate serum antigen, should be monitored regularly. Behavioral changes are sometimes raised as a concern as well. But at physiological replacement levels, mood generally improves rather than destabilizes. The roid rage stereotype comes from super physiological dosing, not replacement therapy.
[34:19 –> 34:55] Other possible side effects include acne, hair loss in men genetically predisposed to balding, fluid retention, gynecomastia if too much testosterone is converted to estradiol. Sleep apnea can worsen if untreated, which is why screening is important before starting therapy. And as we’ve discussed, exogenous testosterone suppresses natural sperm and testosterone production, leading to reduced fertility. That’s not the case with alternatives like emclomiphene or HCG, which preserve fertility. So, yes, there are potential side effects, but most are predictable, monitorable, and manageable with the right dosing and follow-up.
[34:55 –> 35:25] And before we wrap up, I wanna touch on super physiological dosing because a lot of people hear all the benefits of testosterone and think, well, if a physiological dose helps, why not take a lot more? Why not try to become a raging bull of a man with massive muscles, no body fat, and veins popping out everywhere. And that’s exactly what you see in men who take huge doses. Their trapezius muscles are touching their ears, their arms can’t rest at their sides, and their heads look like their temporalis muscles are about to burst out. That look doesn’t happen naturally.
[35:26 –> 35:46] And the truth is, at that point, you’re not getting benefits. You’re actually stacking risks. Some of those changes are even irreversible. High dose steroids affect nearly every organ system. The heart remodels, the left ventricle thickens and pumps less efficiently, lipids shift in the wrong direction, HDL drops and LDL rises, and the arteries become more atherosclerotic.
[35:46 –> 36:11] Atrial fibrillation becomes more common. The kidneys take damage, often showing chronic injury. Blood gets thicker, hematocrit rises, and clot risk goes up dramatically. Meanwhile, the brain’s hormone axis shuts down completely, the testes atrophy, sperm production collapses, and erectile dysfunction and low libido become common. The cruel irony is that these men who look like they’re at the peak of virility often can’t even get an erection.
[36:12 –> 36:43] And if they start young, they may destroy their fertility permanently, sometimes needing enclomiphene or h c g just to attempt a restart. So while society may admire the oversized physiques of famous body builders or influencers, that comes at a steep cost. It’s a form of body dysmorphia, pushing the body into unnatural drug fueled states that are unhealthy and unsustainable. When I talk about testosterone replacement, I’m not talking about that. I’m talking about restoring men to normal physiological range of healthy young adults.
[36:43 –> 37:00] Supraphysiological dosing does no one any favors. So in summary, let’s go back to the original question. Should we replace an older man’s hormones with those of a younger man? Should we replicate the biology of youth in later life? The answer is it depends.
[37:00 –> 37:09] If you’re content with the natural course of aging, there’s nothing wrong with that. Biology has a rhythm. We grow. We blossom. We reproduce.
[37:09 –> 37:31] And eventually, we hand off the continuation of our lineage to the next generation. There’s a certain beauty in that cycle, and embracing it is perfectly fine. But should you still optimize diet and lifestyle at any age? Absolutely. Everyone should aim to give their biology its best shot through good sleep, stress reduction, strength training, and quality nutrition.
[37:31 –> 38:00] That’s the foundation whether you ever touch medication or not. Now if you’ve made those changes and you still feel like you’re stuck in a hole, if you know something’s missing, that vigor and drive that you once had in your twenties, then testosterone replacement can be a reasonable option. The risks are low, and the potential benefits are high. Better sexual function, stronger bones, more lean muscle mass, less fat, improved mood, and a steadier sense of vitality. Before starting, the right workup matters.
[38:00 –> 38:24] Get two morning testosterone checks on different days. Measure total testosterone, free testosterone, and SHBG. Get a CBC, a PSA, blood pressure, liver function test, and a hemoglobin a one c. Screen for sleep apnea and treat it if you have it. Then if the numbers and the symptoms line up, you and your doctor can discuss therapy, and I think it’s totally reasonable at that point.
[38:24 –> 38:44] For most men, injections of testosterone cypionate twice weekly provide the most reliable results. Creams are a good option if needles aren’t for you. And if fertility is important, enclomiphene or HCG can help maintain sperm production. Whatever the method, monitoring is key. Keep an eye on hematocrit, PSA and blood pressure, and estrogenic symptoms.
[38:45 –> 39:10] Adjust if needed, but don’t over treat. You are aiming for a total testosterone of 500 to 900 nanograms per deciliter and a free testosterone of 190 to 274 picograms per milliliter. This will put you in perfect physiological testosterone homeostasis. For younger men, especially those in their teens, twenties, and thirties, my advice is different. You already have youth on your side.
[39:10 –> 39:32] It’s such a great gift. You need to focus on lifestyle, like lifting heavy, sleeping deeply, eating well, managing stress. You need to protect your natural biology while you still have it. And trust me, someday you’ll be my age, and everything will be a steeper climb. Youth is such an amazing gift, and none of us appreciate it when we have it.
[39:32 –> 39:52] And we all envy it when it’s in the rearview mirror. So in the end, whether a man replaces testosterone or not is a deeply personal choice. Some men will embrace the natural aging process. Others will choose to restore physiology to that of his younger version. Modern medicine makes all that possible, and that’s the power of living today.
[39:52 –> 40:07] We can make informed, individualized decisions about our own biology. So I hope you enjoyed that. This episode is just the beginning. It’s a primer on male hormone optimization, and we’ll return to the topic again and again. I’ll be bringing on experts, and we’ll go deeper.
[40:07 –> 40:29] And in the coming weeks, we’ll also turn to female hormone optimization. I already have two outstanding physicians lined up for interviews this November. We’ll also explore thyroid, growth hormone, cortisol, all the key hormones that shape who we are and how we function. So stay tuned. We’re only at the start of this conversation, and there’s a lot more to discover.
[40:29 –> 40:55] In the next episode, we’ll return to tribulations like we do every other week. I’ll be telling the story of a French microbiologist from the nineteen twenties named Henry Bouillard. He was investigating the mysterious resilience of a group of villagers who, while cholera was devastating populations all around them, seemed almost immune. They didn’t get sick. Bouillard went to this village to uncover why, and what he discovered was remarkable.
[40:55 –> 41:13] His exploration struck gold, and it’s something we still use today in medicine. In fact, it’s readily available and still relevant to our lives right now. It’s a fascinating story, and I think you’re really gonna like it. So I hope you’ll join me. But until next time, stay curious, stay critical, and stay healthy.
[41:13 –> 41:13] Cheers.