Men's Health
TESTOSTERONE THERAPY FOR MEN OVER 40
Is Low T real or just marketing? The honest, evidence-based answer is: it depends. Here's how to tell the difference and what to do about it.
Key Facts About Testosterone and Aging
- • Testosterone declines ~1-2% per year after age 30
- • Population-level T has dropped ~25% since the 1980s, independent of age
- • "Normal" lab ranges include sick and elderly men
- • Lifestyle factors (sleep, body fat, stress) account for more decline than aging alone
- • Real deficiency requires symptoms + confirmed low labs on two draws
- • Total T alone is insufficient; free T, SHBG, and LH/FSH matter
- • TRAVERSE trial (2023) showed no increased cardiovascular risk from TRT
- • TRT is not the only option; enclomiphene and lifestyle changes come first
THE REAL DATA ON TESTOSTERONE DECLINE
Let's start with what we actually know, not what supplement ads claim.
Testosterone peaks in the late teens to early 20s. After about age 30, levels decline at roughly 1-2% per year. That's the natural trajectory, and it's been replicated across multiple longitudinal studies, including Harman et al. (2001) in the Baltimore Longitudinal Study of Aging. By age 50, the average man has 20-40% less testosterone than he did at 25. By 70, the drop can exceed 50%.
But here's what most "Low T" marketing doesn't tell you: there's a separate, population-level decline happening on top of individual aging. Travison et al. (2007) compared testosterone levels across generations and found that a 60-year-old man in 2004 had roughly 17% lower testosterone than a 60-year-old man in 1987, at the same age. Something beyond normal aging is driving testosterone down across the entire population. The suspected culprits: rising obesity rates, endocrine-disrupting chemicals, chronic sleep deprivation, sedentary lifestyles, and metabolic disease.
This distinction matters. If you're 45 and your testosterone is 320 ng/dL, some of that is age-related. But some of it may be modifiable. And lumping everything under "you're just getting older" is both scientifically lazy and clinically harmful.
What "Normal" Ranges Actually Mean
Most labs list a "normal" total testosterone range of roughly 264-916 ng/dL or 300-1000 ng/dL. These ranges are derived from large population samples that include obese men, diabetic men, men on opioids, and men in their 80s. A 40-year-old at 310 ng/dL is technically "normal"--but he's sitting at the bottom of a range that includes profoundly unhealthy individuals.
Lab "Normal": ~264-1000 ng/dL (varies by lab)
Endocrine Society Deficiency Threshold: Below 300 ng/dL
Optimal for Most Men (age-adjusted): 500-900 ng/dL
A "normal" result does not mean optimal. Context, symptoms, and free testosterone all matter.
CLINICAL DEFICIENCY VS. NORMAL AGING
The term "andropause" gets thrown around as a male equivalent to menopause, but it's misleading. Women experience a sharp, defined hormonal cliff. Men experience a gradual slope. The question isn't whether testosterone declines--it does. The question is: when does that decline cross from "normal aging" into "something that should be treated?"
Normal Aging Looks Like:
- • Slightly less recovery capacity after workouts
- • Mild, gradual reduction in spontaneous libido
- • Needing a bit more sleep or warm-up time
- • Subtle changes in body composition over years
- • None of these significantly impair daily function
Clinical Deficiency Looks Like:
- • Persistent fatigue that doesn't resolve with rest
- • Near-complete loss of sex drive
- • Erectile dysfunction unrelated to stress
- • Cognitive decline: brain fog, poor memory, lost motivation
- • Significant muscle loss despite training
- • Depression or emotional flatness
- • Rapid body fat accumulation, especially visceral
The Key Distinction
Normal aging is gradual and manageable. Testosterone deficiency impairs function, relationships, work performance, and quality of life. If multiple symptoms from the right column are present, a lab value of 310 ng/dL is not "fine"--regardless of what the reference range says. The Endocrine Society guidelines (Bhasin et al., 2018) are clear: diagnosis requires both symptoms and confirmed low levels on two separate morning blood draws.
THE TRT INDUSTRY PROBLEM
How to tell real medicine from marketing.
The men's health clinic industry has exploded. That's partly good--testosterone deficiency was historically underdiagnosed and undertreated. But it's also created a landscape where marketing outpaces medicine. Many clinics operate on a model designed to prescribe testosterone to as many men as possible, whether they need it or not.
Red Flags in a Testosterone Clinic
- • They "guarantee" you'll qualify for TRT before seeing labs
- • One blood draw, sometimes at 3 PM (T is lowest in the afternoon)
- • They only check total testosterone, nothing else
- • No discussion of lifestyle factors or alternative treatments
- • High-pressure sales tactics or monthly subscription models
- • No plan for ongoing monitoring bloodwork
- • Aggressive upselling of supplements, peptides, or "stacks"
Questions to Ask Any Clinic
- • Will you check LH, FSH, SHBG, and free testosterone?
- • Do you require two confirmed low readings?
- • What's your monitoring protocol after starting treatment?
- • Do you discuss lifestyle optimization before prescribing?
- • How do you handle fertility concerns?
- • What are the actual risks and side effects?
- • When would you recommend stopping treatment?
Why Monitoring Matters
Testosterone therapy isn't "set it and forget it." Without regular bloodwork, you can develop erythrocytosis (dangerously high red blood cell count), estrogen imbalances, lipid changes, or prostate issues--and not know until there's a problem. Any clinic that doesn't require follow-up labs at 6-8 weeks after starting, then every 6-12 months, is cutting corners with your health.
WHAT PROPER EVALUATION LOOKS LIKE
A total testosterone level is a starting point, not a diagnosis. At our clinic in Park Ridge, IL, we run a comprehensive panel because testosterone doesn't exist in isolation. Here's what a thorough evaluation includes and why each marker matters.
The Comprehensive Hormone Panel
- Total Testosterone - The headline number, but only part of the picture
- Free Testosterone - The fraction actually available to tissues; can be low even when total is "normal"
- SHBG - Sex hormone-binding globulin; high SHBG binds T and reduces what's available
- LH & FSH - Distinguish primary (testicular) from secondary (pituitary) hypogonadism
- Estradiol (E2) - Too high or too low causes symptoms; critical for balance
- Prolactin - Elevated levels suppress testosterone and can indicate pituitary issues
- Thyroid Panel (TSH, Free T3, Free T4) - Hypothyroidism mimics low T symptoms almost exactly
- CBC - Baseline hemoglobin/hematocrit before any treatment
- Metabolic Panel + Lipids - Insulin resistance and metabolic syndrome both tank testosterone
- DEXA Scan - Objective body composition data, not guesswork
Why This Matters: A Real Scenario
A 46-year-old man comes in fatigued, gaining weight, with low libido. His total testosterone is 380 ng/dL--"normal." But his SHBG is 65 nmol/L (high), making his free testosterone critically low. His TSH is 5.2 (subclinical hypothyroid). His fasting insulin is 18 (insulin resistant). If you only checked total T, you'd send him home and tell him he's fine. A comprehensive panel reveals three treatable problems. This is why the panel matters.
TREATMENT OPTIONS BEYOND JUST TESTOSTERONE
TRT gets all the attention, but it's not the only tool and it's not always the right first move.
Lifestyle Optimization (Always the Foundation)
Before any prescription, lifestyle factors must be addressed. Not because they're a polite suggestion--because they're often the primary driver of low levels. We'll cover these in detail below, but the short version: if you're sleeping 5 hours, carrying 40 extra pounds, chronically stressed, and drinking regularly, your testosterone is low because of those things. Fixing them first isn't optional.
Enclomiphene
A selective estrogen receptor modulator that stimulates your pituitary to increase LH and FSH, which signals your testes to produce more testosterone naturally.
Best for: Younger men, men wanting to preserve fertility, secondary hypogonadism, men who want to maintain natural production.
HCG (Human Chorionic Gonadotropin)
Mimics LH, stimulating the testes directly. Often used alongside TRT to maintain testicular function and fertility, or as standalone therapy for mild cases.
Best for: Fertility preservation during TRT, maintaining testicular size, mild deficiency where TRT isn't yet warranted.
TRT (Testosterone Replacement)
Exogenous testosterone via injection, topical gel, or pellets. The most direct and effective option for confirmed deficiency, but it suppresses natural production.
Best for: Confirmed hypogonadism unresponsive to lifestyle changes, primary testicular failure, symptomatic men with levels consistently below 300 ng/dL.
The Honest Sequencing
Step 1: Optimize sleep, body composition, stress, and training. Step 2: Retest in 8-12 weeks. Step 3: If still deficient with symptoms, consider enclomiphene or HCG. Step 4: If those are insufficient or inappropriate, TRT with proper monitoring. Skipping straight to Step 4 without addressing Steps 1-3 is bad medicine--even if it's common practice.
LIFESTYLE FACTORS THAT TANK TESTOSTERONE
Before blaming your age, audit these. Many men over 40 have low testosterone not because of aging, but because of how they're living.
Sleep Deprivation
The single biggest modifiable factor. One week of sleeping 5 hours per night reduces testosterone by 10-15% (Leproult & Van Cauter, 2011). Most testosterone is produced during deep sleep. If you're getting less than 7 hours or have untreated sleep apnea, your testosterone is lower than it needs to be.
Chronic Stress & Cortisol
Cortisol and testosterone are inversely related. Chronic stress--work pressure, financial strain, relationship conflict, overtraining--keeps cortisol elevated, which directly suppresses GnRH and downstream testosterone production. This isn't woo-woo; it's endocrinology.
Excess Body Fat
Adipose tissue contains aromatase, an enzyme that converts testosterone to estradiol. More body fat means more conversion, which means less circulating testosterone and more estrogen. This creates a vicious cycle: low T promotes fat storage, which further lowers T. Body fat above 25% in men is strongly correlated with reduced testosterone.
Alcohol
Alcohol directly suppresses testosterone production, increases aromatase activity, raises cortisol, disrupts sleep architecture, and impairs liver clearance of estrogen. Even "moderate" drinking (2+ drinks daily) has measurable effects on testosterone. The dose-response is clear: more alcohol equals lower T.
Training Errors
Overtraining with inadequate recovery suppresses testosterone through chronic cortisol elevation. Conversely, not training at all--or only doing cardio--misses the acute testosterone boost from heavy compound resistance training. The sweet spot: 3-4 days of strength training with adequate recovery, not 7-day-a-week marathon sessions.
Micronutrient Deficiencies
Vitamin D, zinc, and magnesium are all directly involved in testosterone synthesis. Deficiencies are extremely common, especially in northern latitudes. A vitamin D level below 30 ng/mL is associated with lower testosterone. These are simple, cheap fixes--but they're often overlooked.
LONG-TERM SAFETY: WHAT THE DATA ACTUALLY SHOWS
The safety conversation around TRT has been clouded by bad studies, media headlines, and clinic marketing. Here's what the evidence says as of 2024.
Cardiovascular Safety
The TRAVERSE trial (Lincoff et al., 2023) is the landmark study here. It enrolled over 5,000 men aged 45-80 with hypogonadism and pre-existing or high risk of cardiovascular disease. Result: testosterone therapy did not increase the risk of major adverse cardiovascular events (heart attack, stroke, cardiovascular death) compared to placebo.
Earlier studies that raised cardiovascular concerns (Vigen 2013, Finkle 2014) had significant methodological flaws and have been widely criticized. The current Endocrine Society position is that TRT does not appear to increase cardiovascular risk when used appropriately.
Prostate Safety
The old belief that testosterone "feeds" prostate cancer has been largely debunked. The saturation model (Morgentaler & Traish, 2009) demonstrates that prostate tissue saturates at relatively low testosterone levels, and raising T from low to normal does not stimulate prostate growth in most men.
That said, active prostate cancer remains a contraindication. PSA should be monitored before and during treatment. A rising PSA doesn't necessarily mean cancer, but it requires investigation. The TRAVERSE trial also showed a modest increase in prostate biopsies in the TRT group, warranting ongoing surveillance.
What Must Be Monitored
- Hematocrit/Hemoglobin - TRT increases red blood cell production; levels above 54% hematocrit increase clot risk
- PSA - Baseline and periodic checks to screen for prostate changes
- Estradiol - Excess aromatization can cause symptoms; may need management
- Lipid Panel - TRT can reduce HDL; should be tracked
- Blood Pressure - Fluid retention can increase BP in some men
- Liver & Kidney Function - Standard safety monitoring
The bottom line on safety: Properly monitored TRT at physiologic doses has a favorable risk profile for men with confirmed hypogonadism. The risks of untreated testosterone deficiency--metabolic syndrome, osteoporosis, depression, cardiovascular disease--often outweigh treatment risks. But "properly monitored" is the operative phrase. Without regular bloodwork and clinical oversight, risks increase substantially.
COMMON QUESTIONS
Is testosterone decline after 40 inevitable?
Some decline is normal--about 1-2% per year after age 30. But severe drops aren't inevitable. Population studies show that much of the decline attributed to aging is actually driven by weight gain, poor sleep, chronic stress, and metabolic disease. A healthy 50-year-old can maintain testosterone levels well above the deficiency threshold.
What testosterone level is too low for a man over 40?
The Endocrine Society defines deficiency as total testosterone below 300 ng/dL with symptoms. However, symptoms can occur at 300-450 ng/dL because lab "normal" ranges include sick and elderly men. Context matters: a 42-year-old at 310 ng/dL with fatigue, low libido, and brain fog is clinically different from an asymptomatic 42-year-old at the same level. Free testosterone and SHBG must also be evaluated.
How do I know if a testosterone clinic is legitimate?
Red flags include: guaranteeing you need TRT before seeing lab results, not checking LH/FSH or thyroid, no discussion of lifestyle factors first, no ongoing monitoring plan, prescribing based on a single blood draw, and aggressive upselling of supplements or peptides. A legitimate clinic will run comprehensive labs, discuss non-pharmaceutical options, explain risks honestly, and require regular follow-up bloodwork.
Can I improve testosterone naturally after 40?
Yes, in many cases. Losing excess body fat, strength training with compound movements, sleeping 7-8 hours, managing stress, limiting alcohol, and correcting micronutrient deficiencies (vitamin D, zinc, magnesium) can raise testosterone meaningfully. Some men see increases of 100-200 ng/dL through lifestyle alone. However, if levels are severely low or there's a primary testicular issue, lifestyle changes won't be sufficient.
Is TRT safe long-term?
The TRAVERSE trial (2023)--the largest cardiovascular safety trial for TRT--found no increased risk of major cardiovascular events in men with hypogonadism. Long-term data shows TRT is generally safe when properly monitored. Key monitoring includes: hematocrit/hemoglobin (TRT increases red blood cells), PSA (prostate marker), lipid panels, and blood pressure. Risks increase without monitoring or with supraphysiologic dosing.
Will testosterone therapy affect my fertility?
Exogenous testosterone suppresses sperm production--sometimes to zero--by shutting down LH and FSH signaling. This is usually reversible but not guaranteed. If fertility is a concern, alternatives like enclomiphene or HCG can raise testosterone while preserving sperm production. This must be discussed before starting treatment, not after.
References
- 1. Bhasin S, et al. "Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline." J Clin Endocrinol Metab. 2018;103(5):1715-1744.
- 2. Travison TG, et al. "A Population-Level Decline in Serum Testosterone Levels in American Men." J Clin Endocrinol Metab. 2007;92(1):196-202.
- 3. Harman SM, et al. "Longitudinal Effects of Aging on Serum Total and Free Testosterone Levels in Healthy Men." J Clin Endocrinol Metab. 2001;86(2):724-731.
- 4. Lincoff AM, et al. "Cardiovascular Safety of Testosterone-Replacement Therapy." N Engl J Med. 2023;389(2):107-117. (TRAVERSE Trial)
- 5. Leproult R, Van Cauter E. "Effect of 1 Week of Sleep Restriction on Testosterone Levels in Young Healthy Men." JAMA. 2011;305(21):2173-2174.
- 6. Morgentaler A, Traish AM. "Shifting the Paradigm of Testosterone and Prostate Cancer: The Saturation Model and the Limits of Androgen-Dependent Growth." Eur Urol. 2009;55(2):310-320.
- 7. Snyder PJ, et al. "Effects of Testosterone Treatment in Older Men." N Engl J Med. 2016;374(7):611-624.
- 8. Mulhall JP, et al. "Evaluation and Management of Testosterone Deficiency: AUA Guideline." J Urol. 2018;200(2):423-432.
- 9. Corona G, et al. "Testosterone and metabolic syndrome: a meta-analysis study." J Sex Med. 2011;8(1):272-283.
- 10. Camacho EM, et al. "Age-associated changes in hypothalamic-pituitary-testicular function in middle-aged and older men are modified by weight change and lifestyle factors." Eur J Endocrinol. 2013;168(3):445-455.
READY TO FIND OUT WHERE YOU ACTUALLY STAND?
Comprehensive hormone panel. Not just total testosterone. Real evaluation, honest answers, no sales pitch. Park Ridge, IL.