By Tom Davis—November 21st, 2021
It wasn’t until I heard the following statements being said aloud on a late night television commercial some years ago that I began to recognize that I had low testosterone:
Guys, are you feeling more sluggish than usual? Don’t have that same energy you had when you were younger? Not as active in the bedroom? Having difficulty performing?…
That commercial turned out, of course, to be an ad for an aphrodisiac cleverly marketed as a “testosterone booster,” a phrase that, when uttered within earshot, acts as a sort of dog whistle to men to appeal to their proclivity toward enhancing their masculinity.
Turns out, that commercial was targeted toward guys like me, as I certainly fit the criteria they outlined for why I should buy their product. Rather than pick up the phone and dial their 1-800 number, I instead found myself investigating these symptoms, the symptoms of low testosterone, and why I had them at the young age of 27.
The symptoms of low testosterone are sundry, but most of them are probably what you’d expect. Some of the more common symptoms are:
Muscle atrophy or difficulty building muscle
In the interest of full disclosure, I will tell you that I had all the symptoms in the book, including those in the aforementioned bulleted list. It’s said that, on average, men’s testosterone levels decrease by about 1% each year after the age of 30, so why at the age of 27 was I already experiencing the symptoms that a man more typically in his 60’s or 70’s would?
It was shortly thereafter that I made an appointment with my general practitioner to run some blood work and hopefully confirm my self-diagnosis of low testosterone. Odd as it may sound, I was really hoping that I did indeed have low testosterone, as that seemed like the most sensible explanation for my symptoms. Further, after doing some research, I became familiar with the protocol for treating these symptoms medicinally. I was hopeful that starting a course of treatment, thus alleviating my symptoms, was just a blood test confirmation away.
Testosterone levels are most accurately measured by doing blood work. There are two significant levels to look at: total testosterone and, the more significant of the two, free testosterone (also known as bioavailable testosterone). Total testosterone is as the name implies: the total amount of testosterone in your bloodstream, measured in nanograms per deciliter (ng/dL). Free testosterone is the amount of testosterone that is not bound to a protein called Steroid Hormone Binding Globulin (SHGB) and is also as the name implies: the amount of testosterone that is free for the body to use. It is normal for around 98% of a man’s total testosterone to be bound to SHGB, leaving the remaining 2% bioavailable for absorption, leading to the creation of secondary sex characteristics, such as a deeper voice, facial hair and muscle growth.
When ordering blood work to measure testosterone levels, it’s not uncommon for physicians to initially neglect checking free testosterone and focus only on total testosterone. That’s because, by and large, doctors tend to rely on total testosterone as the operative metric to determine whether or not to diagnose a man with low testosterone, or more specifically, hypogonadism.
When measuring a man’s total testosterone, there seems to be a general consensus in the medical community that anything lower than 300 ng/dl constitutes abnormally low testosterone and may merit a diagnosis of hypogonadism, whereas anything above 1,100 ng/dl constitutes abnormally high levels of testosterone and might suggest anabolic steroid use. Unfortunately, unless you see a specialist, such as a urologist, or better still, an endocrinologist, your doctor may not take into account your age and overall health as factors that would suggest what a normal level for you ought to be.
For example, while the standard range for measuring total testosterone is generally 300 ng/dl to 1,100 ng/dl, just because your levels tested at say, 350 ng/dl, does not necessarily substantiate the claim that you’re “within normal range.” There’s quite a disparity between the high and low end of that spectrum, after all. The way this scale was conceived was by getting the average total testosterone levels of men aged 16 to 65, so it would stand to reason that a man who is in his mid sixties, perhaps with a medical condition such as type 1 diabetes, would score nearer the bottom of the scale, whereas an 18 year old athlete would score closer to the top end of the spectrum.
Having consulted a general practitioner, rather than a specialist, I was fortunate to test just below 300 at 271 ng/dl, as my doctor would have otherwise told me that I was on the low end but “within normal range.” Admittedly, he explained that if my blood work came back at any number higher than 300 he would recommend that I get more sleep, supplement with vitamin D, and prescribe a host of other treatments that would not involve prescription drugs or hormone replacement therapy.
After confirming my levels with a subsequent blood test a month later, my doctor begrudgingly concluded that I should receive prescription testosterone. He, like most doctors, seemed to exhibit a sort of stigma against prescribing testosterone to an otherwise healthy, weightlifting young man. In my estimation, a part of that reluctance he felt was probably due to the fact that I was especially young to receive this otherwise unorthodox treatment. He knew that I lifted weights regularly too, and if not for the blood tests substantiating the necessity for this treatment, he would probably be under the assumption that I just wanted a prescription for “steroids” as many young weightlifters stereotypically would.
The other part of that reluctance that I sensed is this attitude that seems to be pervasive among many medical doctors with regard to testosterone treatment for men. This attitude that I’m speaking of is really more of a philosophical disposition than a medical one, and it suggests that men ought to accept their age, their dwindling quality of life, and not combat the aging process by way of testosterone replacement therapy. It’s as though it is expected that men will slow down with age and that they must also accept this fate without any recourse except by naturalistic means. I think this is an archaic way of thinking for civilized intellectuals and medical professionals in the 21st century, but what do I know; I’m just a guy with a Youtube account.
To my dismay, my doctor initially recommended a testosterone cream as the treatment modality, which I had researched and found to be less efficacious based on what I had read about it. Additionally, the cream required a daily topical application, whereas intramuscular injections, my preferred method, required only weekly or biweekly applications; but far be it for me to challenge the professional opinion of my somewhat supercilious doctor with only “bro science” or anecdotal testimony from Youtube videos as my counter evidence. Instead, I told him that I had researched the creams and learned that, even with insurance, they are considerably expensive compared to injections, which I had learned were both cheap and effective. After expressing a little frustration and hopelessness with his initial recommendation, he eventually conceded that I could receive the injections instead of the cream.
He prescribed me 100mg of testosterone cypionate to be injected intramuscularly once per week. 100mg/week is a standard starting dose that can later be raised or lowered depending on how effective it ends up being. Much as it’s true for most anything related to medicine, everyone’s body will react differently to the introduction of exogenous testosterone, so follow-up blood tests should be performed regularly starting at 3 months after the first treatment to monitor the change in testosterone levels in the bloodstream. This protocol is especially true for intramuscular injections, as it typically takes 3-5 months to fully saturate the androgen receptors so as to get an accurate, consistent measurement.
I remember that first injection very distinctly. I swabbed the top of the testosterone vial with alcohol, punctured it with a needle, withdrew 100mg of testosterone into the syringe, and then removed the needle from the vial. I then replaced that needle with a thinner one—the one that I was going to use to inject myself with—and just stared at it for several minutes, wondering how the hell I was going to handle the injection. Remember, this was going to be an intramuscular injection, not a subcutaneous one like the ones used to inject insulin in people with type 1 diabetes. We’re talking a 1 to 1 ½ inch needle going into the muscle at a 90° angle. Yikes!
My life was full of what the hells, and coupled with the daunting reality that if I didn’t inject this that my symptoms would persist, I sucked it up and decided to just go for it. The site location I chose for my injection was my right outer thigh, which is one of 3 typical injection sites for these kinds of injections since it is deep and rich in muscle fibers. The other popular spots are the upper part of the buttocks and the deltoid. The idea is to inject the testosterone deep into the muscle where it will be best absorbed by the body.
The last part of my newfound ritual was wiping my outer thigh with an alcohol pad to decontaminate the injection site and reduce the risk of infection. Once this was completed, I waited a few seconds for the alcohol to dry so that the needle wouldn’t sting as much, firmly grasped a thick wad of muscle surrounding the spot where I was going to stab myself, bit my tongue, and began inserting the needle until all 1 ½ inches of it were submerged below the surface. To my surprise, it didn’t hurt one bit!
The next step was to aspirate, or draw back on the plunger to see if any blood entered the syringe. If that happens, it means that the needle has landed inside a blood vessel and I would need to remove the needle and reinsert it until I found a spot that was purely muscle. Injecting into a blood vessel would mean injecting oil directly into my bloodstream, which could cause symptoms as mild as an immediate cough or as severe as a fatal stroke.
The next step in the process was to push down on the plunger until all of the testosterone left the syringe and went into my body. This was more difficult than you would imagine. The width of the needle affects how quickly this can be achieved. Using a 25 gauge needle—what most would consider to be a standard size for such a task—it took a great deal of pressure to completely expel the testosterone into my leg.
Before I knew it, the hardest parts were over. I stabbed myself, aspirated, confirmed it was a good spot, injected the testosterone, but I still wasn’t home free. I still had to remove the needle from my leg, a fearful prospect for a first-time needle user like me, let me tell you. I figured it was best to just pull it out of my leg as straight and as quickly as possible, and so I did. Again, with no pain. Success!
A few months later, I had blood work done again to see what my new level of total testosterone was. It was a meager 420, which I found to be a disappointing level of improvement, although many of my symptoms had already been alleviated by this point.
In the midst of waiting for that follow-up blood test to take place, my doctor ordered me an MRI scan of my pituitary gland. The pituitary gland, I learned, is an integral part of testosterone production, as it creates a hormone called luteinizing hormone (LH) which ultimately travels to the testes to signal them to make both testosterone and sperm. The idea behind the MRI was to determine what official diagnosis to give me, either primary or secondary hypogonadism.
As I mentioned earlier, hypogonadism is a diagnosis of low testosterone, but a man is diagnosed as having either primary or secondary hypogonadism, specifically. Primary hypogonadism simply means that the deficiency in testosterone production stems from within the gonads, or testes, themselves. Conversely, a diagnosis of secondary hypogonadism means that the issue stems from higher up the ladder, such as from the pituitary gland where LH is produced.
It turns out, I had secondary hypogonadism, as the MRI revealed that I had a flattened pituitary gland, a condition known as empty sella syndrome. I learned that the cause of this was either genetic or due to severe or repeated impact to my head. I had no family history of low testosterone or any hormone deficiencies of any kind. I had been in combat martial arts my whole life, but the amount of times I’d taken a hit to the noggin was most definitely unremarkable that it could not be given credence as to the cause of this condition. To this day, I remain scratching my head (and not because of an irritated, flattened pituitary gland), wondering what caused this condition.
As of this writing, I am 31 years old and have been on testosterone replacement therapy for 4 years now. From my own experience, I will submit that a diagnosis of low testosterone as a consideration for the cause of depression is most certainly often overlooked, by both doctors and patients alike, but it is an avenue worth exploring in men. The symptoms of low testosterone that manifest are not all physical, after all.
I can honestly say that treating my secondary hypogonadism with testosterone replacement therapy proved to be successful in treating all of my symptoms. I continue a regular treatment protocol that consists of weekly injections of 200mg of testosterone cypionate per week now, and it has done wonders for my quality of life.
I hope that by sharing my journey toward testosterone replacement therapy I am able to inspire other men to explore this avenue of treatment if their quality of life has been diminishing. There’s treatment out there—and it works!