Low Testosterone (Low T)

Low testosterone is a natural condition that occurs when a man’s sex hormone production (primarily testosterone and DHT) starts to decline. This condition is also called male menopause, man-o-pause, andropause, and  low T. Low testosterone is marked by a reduction in testosterone levels, sex drive, sexual performance, mental clarity, concentration, energy, strength, bone density, body hair, as well as a zest for life and passionate interest in activities or family events.

This lack of male sex hormones happens to all men if they live long enough. If a man’s old enough to join AARP, chances are he’s noticed that his sex drive, memory, vitality, and workouts aren’t what they used to be 20 years ago; although, some men don’t notice this change until they’re well into their 70s. It all depends upon how high a man’s sex hormone levels were in his prime and how far those levels have fallen over time.

Unlike female menopause, which is defined by an inability to conceive and a sharp drop in the female sex hormones (estrogen and progesterone), a man’s testosterone level drops slowly over decades. After a man reaches the age of 30, testosterone production declines approximately 10 percent per decade (one percent per year). This loss of testosterone is insipid; it occurs so slowly that many men don’t notice it until they wake up one day feeling old and tired.

Testosterone production (or lack of it), however, is only part of the picture. Men respond differently to this decline. For example, if you took two men with the same level of testosterone (let’s say 400 ng/dl), one might have several andropause symptoms, while the other has none.

This apparent paradox is solved when you learn that the man with the andropause symptoms had a testosterone level of 800 ng/dl when he was at his peak, which means that he now only has half that level of the testosterone circulating in his blood — that’s a big drop. The other man only had a lifetime high of 500 ng/dl, so his drop is not as significant, and therefore not as big a loss to his system. A key point to remember here is that numbers don’t tell the whole story.

In order to create a customized testosterone treatment plan, we integrate blood chemistry information with the patient’s overall health, a physical exam, medical history, symptoms — plus we listen to our patients to hear what they think is missing from their life — before we formulate a treatment plan.

How Common is Low Testosterone?

It’s a safe bet that most men over 50 experience some andropause symptoms on a semi-regular basis. Unfortunately, the medical information on the topic is a little murky. Several major demographic studies on testosterone deficiency (hypogonadism) cloud the prevalence of this issue by using different criteria as well as men of different ages — sort of like comparing apples to grapefruit. For example, the 2006 Hypogonadism in Males study concluded that 39 percent of men 45-70 were hypogonadal, while the 2010 European Aging Male study of men 40-79 combined low testosterone with three behavioral markers and found that their overall measure of hypogonadism was 2.1 percent. Obviously, there’s a huge disparity between these numbers.

In addition to testosterone levels, the age at which a man starts to feel the effects of andropause also depend upon:

  • Overall health
  • Use of certain prescription medications (corticosteroids, alpha blockers, drugs to treat prostate cancer)
  • Body Mass Index
  • Diseases like diabetes, high blood pressure, and metabolic syndrome
  • Fitness level
  • The presence of depression and/or anxiety
  • Heredity factors

Low Testosterone Prevention

  • Diet (avoid estrogenic foods including all soy products)
  • Exercise (engage in weight bearing exercise: walking, hiking, running, weight lifting, sports, dancing, and so on)
  • Supplements
  • Herbs
  • Stress Reduction/Biofeedback
  • Limit alcohol to one drink/day

Diagnostic Tools for Low Testosterone

  • Medical history
  • Physical exam (testicular atrophy, testicular damage, and so on)
  • Body composition (Body Mass Index, DXA bone density scan, muscle composition testing)
  • Hormonal tests to see which ones are deficient (testosterone, testosterone/estrogen ratio, DHT, DHEA, and others)
  •  Heart health tests (LDL, HDL, and other lipids).
  • Patient self-reports a gradual loss in any of the following areas:
    •  Sex drive
    • Ability to have and/or maintain an erection (ED)
    •  Mental clarity & concentration
    • Thirst for life
    • Passionate interest in the world around them
    • Energy
    • Strength/Recovery from exercise
    • Enthusiasm
    • General interest in events that were previously enjoyable

Treatment for Low Testosterone

As physicians with over 65 years combined experience in men’s health, it’s our job is determine deficiencies, excesses, and imbalances in hormones, neurotransmitters, and lifestyle. We also evaluate how well the entire endocrine system is communicating and interacting to produce maximum health and wellness.

In-Office Care

  • Nutritional, hormonal, and neurotransmitter counseling
  • Medication evaluation/modification
  • Lifestyle modification program
  •  Herbs
  • Supplements
  • Diet
  •  Exercise programs
  • Physical Therapy
  • Acupuncture

Hormone Replacement Therapy

All our hormone therapy treatment plans are designed to fit the patient’s specific needs. We also take the time to analyze all the relevant laboratory data and combine that with a medical history, plus the biochemical, neurologic, and metabolic pathways that are unique to each patient.

We are not affiliated with any particular pharmacy (or pharmaceutical manufacturer). We do, however, prefer to work with pharmacies that specialize in bioidentical hormone replacement therapy (BHRT). Bioidentical hormones are completely natural and identical to the ones your body produces.

All of our BHRT delivery systems bypass the liver. Why? Because the liver metabolizes testosterone and other male sex hormones before they reach their intended targets, rendering them useless. This process also damages the liver.

The following is a brief discussion of the different hormone deliver systems we recommend.

BLA Tablets

When testosterone is given orally, it is broken down quickly by the liver (in what is known as the “first pass effect”). Pharmaceutical researchers have attempted to bioengineer the testosterone molecule so that the liver doesn’t metabolize it; however, to date, all attempts to alter this important human hormone have turned it into a liver toxin.

In an effort to avoid this testosterone delivery issue (and the accompanying liver toxicity problem), Belmar Pharmacy developed it’s own proprietary delivery method for bio-identical hormones called Bio-available Lymphatic Absorption (BLA) Lipid Matrix System. These oral lipid capsules avoid the “first-pass effect” because they are absorbed by the lymphatic system in the villi of the intestine — instead of the normal metabolic pathway that runs from the villi’s capillaries to the portal veins and on to the liver.

Bypassing the “first pass effect” allows testosterone and other androgens to be delivered by mouth, which is a huge advantage for many patients.


Testosterone pellets are the oldest form of testosterone replacement therapy. The longevity of this mode of testosterone delivery is a tribute to its safety and efficacy.

Compounded bioidentical pellets are placed just beneath the skin to provide consistent hormone therapy for up to six months — without any of the ups and downs in libido, mood, or energy that can accompany other hormone delivery methods.

The biggest advantage of this type of hormone delivery system is the peace of mind that comes from knowing it’s working — without having to take a pill twice a day, apply a gel, put on a patch, or make an appointment for the next injection.

The only drawback to this BHRT delivery method is that inserting the pellets requires an office visit.

Topical Gels and Creams

Creams and gels are simple and effective ways to deliver hormone replacement therapy. Because they are absorbed directly through the skin, they avoid the “first-pass effect,” and are therefore gentle on the liver. Once absorbed into the skin, testosterone and other steroids are released gradually into circulation for several hours.

One advantage of gels and creams over patches is a general reduction in patients’ percentage of body fat.

The disadvantage of creams and gels is the possibility of transmission to anyone with whom you have skin-to-skin contact before the gel or cream dries completely, which takes about 15 minutes.

Attention needs to be paid to the timing of application of gels and creams to mimic the body’s natural twice-a-day rise in testosterone production.

Transdermal (Skin) Patches

Like gels and creams, these easy-to-apply patches allow for bioidentical hormones to be absorbed directly through the skin where they are stored and released slowly over the course of 24 hours. The advantage of this delivery method is that peeling off one patch before bed and pressing on another one takes 15 seconds. The disadvantage is the glue used to adhere the patch to your skin can cause irritation, rashes, and hair loss near the patches.

Because of their ease of use, gels and creams have largely replaced transdermal patches as a hormone delivery method.


Unlike old-school testosterone injections where patients received large doses of the hormone that peaked quickly and declined just as fast (putting the poor patient on a hormonal roller coaster that alternated between mania and lethargy), modern hormone injections therapy involves smaller doses of androgens that are injected more frequently (approximately every two weeks).

Today’s androgen injections are supplemented by Human Chorionic Gonadotropin (HCG) therapy on the weeks between injections, which helps to balance the patient’s hormone levels, metabolism, and emotional life.

The advantages of androgen injections are cost and convenience. The disadvantage is some men simply do not like needles.

The Next Step

There really is no way to evaluate which of these male sex hormone delivery methods is best for you without a complete medical history and physical exam. To set up an initial consultation about bioidentical hormone replacement therapy, please contact Choices in Health at 303-554-4444.