Testosterone replacement therapy (TRT), available as injections, patches, gels, pills and implant pellets, was a global market worth nearly $2 billion in 2022, and is projected to reach nearly $3 billion by 2032, according to Allied Market Research. Yet TRT is often misused for symptoms like fatigue or for athletic enhancement, when it is actually meant to treat clinically diagnosed low testosterone.

While this pivotal sex hormone is responsible for male puberty, sperm production and healthy libido, it also acts as a critical metabolic regulator and driving force behind physical energy, healthy muscle mass, bone density, red blood cell production and mood regulation. When men experience a decline in performance—whether at work, in the gym or in the bedroom—it may be easy to assume that low testosterone levels are to blame, but the misuse or overuse of TRT places users at risk for undesirable side effects.

According to the Mayo Clinic, the potential risks of TRT include: worsening sleep apnea; skin reactions, including acne; noncancerous growth of the prostate and growth of an existing prostate cancer; enlargement of the breasts; a reduction of sperm production; and overproduction of red blood cells, which could lead to a life-threatening pulmonary embolism. In addition, according to a 2018 study in the World Journal of Men’s Health, TRT can cause infertility.

 

Reaching the Correct Diagnosis

The American Urological Association defines low testosterone as a total blood serum level below 300 nanograms per deciliter (ng/dL) on at least two separate early morning tests, accompanied by symptoms like low sex drive and performance, fatigue, loss of muscle mass, increased body fat and depression.

“Many men are seeking TRT to treat nonspecific symptoms like general fatigue, weight gain or a slight dip in motivation—issues that are often the result of lifestyle factors, rather than low testosterone,” says Dr. Joel Fuhrman, president of the Nutritional Research Foundation and the author of several books, including Eat for Life and Eat to Live Cookbook. In light of the trend of TRT over-prescription and the considerable risks, Fuhrman stresses the importance of considering effective natural methods to restore hormonal balance.

Men can experience a decline in their testosterone levels for reasons beyond testosterone deficiency. “Thyroid problems, vitamin D deficiency, high prolactin [hormone], chronic stress, certain medications, opioids and antidepressants all suppress testosterone or mimic its symptoms. Run a full panel before assuming it’s your testosterone. You might be chasing the wrong problem,” advises Nelson Vergel, a hormone therapy researcher, men’s health educator and creator of ExcelMale.com, an online men’s health and TRT forum.

Vergel highlights the devastating effects of chronic unresolved stress, which “tells the brain to dial back testosterone production. It’s a survival mechanism; your body prioritizes threat-response over reproduction. It makes sense in the short term, but it’s devastating long-term.”

Raymond Wohl, the medical director of Chicago Male Clinic in Chicago, Illinois, says, “A decline in performance, libido or confidence is often an early warning sign of underlying issues such as elevated stress, reduced blood flow, hormonal imbalance or metabolic dysfunction.” Men are often surprised to discover that improvements in energy, sleep, weight management and mood frequently accompany enhanced sexual performance. Wohl emphasizes, “Sexual health is not separate—it’s a powerful indicator of total wellness. We recommend TRT only after a thorough evaluation, including lab work, symptom analysis and lifestyle review.”

Functional medicine specialist and men’s health coach Dr. Andreas Boettcher, in Lakewood Ranch, Florida, also recommends a comprehensive approach. “You need to look at the full hormonal picture, including cortisol patterns across the day; levels of DHEA-sulfate, pregnenolone, estradiol and prolactin; thyroid function, including free T3 conversion; and insulin markers,” he explains, naming multiple hormones besides testosterone.

Addressing the gut-hormone axis—the network involving the gastrointestinal tract, gut microbiome and endocrine system—is also high on Boettcher’s radar. “Hormone metabolism, balance and excretion are deeply dependent on your gut,” he points out. “The gut microbiome influences the signaling of virtually every hormone in the body, but the gut-hormone axis is a two-way communication highway, and when it breaks down—through gut permeability, dysbiosis [imbalance of gut flora] or chronic inflammation, hormone balance becomes nearly impossible to achieve, regardless of what else you do.”

Boettcher attests that approximately 80 percent of men receiving hormonal support no longer need TRT once the underlying factors are adequately addressed. Given the right environment, he explains, the endocrine system begins production at levels that restore vitality, energy, lean muscle mass and libido. During his mid-to-late 40s, Boettcher quadrupled his testosterone levels without resorting to TRT or shortcuts. Now approaching 60, he maintains a single-digit body fat percentage, which he attributes to consistent daily choices. He asserts that men are biologically designed to be lean, strong and metabolically healthy well into the latter half of life.

 

Testosterone Disruptors and Supporters

Vergel reports that a significant portion of his patients that were convinced they had low testosterone turned out to have undiagnosed sleep apnea. “Just one week of sleeping only five hours a night drops testosterone by 10 to 15 percent in otherwise healthy men,” he says. “That’s not trivial. Everything else you’re doing—diet, training or supplements—gets undermined if you’re chronically sleep-deprived. Fix the sleep, and testosterone often comes back on its own.”

Psychological factors should also be considered. “Men who have carried unaddressed trauma for years often look hormonally like someone 15 to 20 years older with lower testosterone, lower DHEA [a testosterone precursor], disrupted sleep and blunted growth hormone,” says Vergel. “No dose of TRT fully compensates for an unresolved psychological load. You have to work both sides.”

Boettcher emphasizes the role of alcohol as an underestimated and significant contributor to hormonal anomalies. “Even moderate, consistent alcohol consumption impairs liver function, and your liver is the primary site of estrogen clearance,” he explains. “Disrupt that clearance and estrogen accumulates, testosterone declines and the hormonal balance tips in exactly the wrong direction.”

Boettcher also highlights the potential damage caused by Ibuprofen, a common over-the-counter medication. Over time, chronic use can damage the gut lining, impair nutrient absorption and disrupt the raw materials the body needs to produce hormones.

Before making a lifelong commitment to hormone therapy, Fuhrman believes that most men can significantly improve their bioavailable testosterone levels by reducing body fat. “Adipose tissue contains high levels of the enzyme aromatase, which converts your existing testosterone into estrogen. Losing weight keeps your natural testosterone in circulation.”

He recommends resistance training, specifically compound movements such as squats, deadlifts, bench presses and curls to trigger a metabolic and hormonal signaling environment. He also suggests a diet rich in green salads and vegetables, including broccoli, kale and arugula; polyphenol-rich foods such as beans to promote a healthy gut microbiome; and omega-3-rich nuts and seeds (walnuts, chia, flax and sesame seeds) to reduce the risk of cardiovascular disease and cognitive decline.

Vergel cautions against ultra-processed food and excessive sugar consumption, which contribute to abdominal fat accumulation. He emphasizes the importance of clean protein and healthy dietary fats. “Don’t fear fat,” he remarks. “Testosterone is synthesized from cholesterol, so olive oil, eggs, avocados and quality meat protein aren’t your enemies.”

 

Vitality at Any Age

Ultimately, feeling well enough to live life to the fullest is not exclusive to a fortunate few. Vergel asserts, “The men I’ve seen most vital in their 60s and 70s are the ones who didn’t accept decline as inevitable. They asked questions, found good doctors and stayed in the game.”

Wohl offers hope and inspiration, saying, “Aging is inevitable, but decline is not. Sexual health does not have an expiration date. With the right interventions, men can maintain, and often regain, high levels of vitality well into later decades. Our oldest patient is 84 and still thriving.”

 

Marlaina Donato is an author, painter and composer. Connect at WildflowersAndWoodsmoke.com.

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