Testosterone deficiency or “hypogonadism” is believed to have a prevalence rate of nearly 40% of men over 45 and continues to increase, affecting nearly 50% of all men by the age of 80 (Sizar et al., 2023; Baqir et al, 2023; Dhindsa et al., 2010).

In men, early morning normal testosterone levels are 300 ng/dL to 1000 ng/dL (Sizar et al., 2023).

• In elderly men, levels are ideally 500 to 800 ng/ dL
• In young men, levels are optimal at 600 to 900 ng/ dL
• In men, levels of free testosterone are to be between 50-280 pg/ dL
• In women of reproductive age, levels ranged between 15-46 ng/ dL
• In women of reproductive age, levels of free testosterone ranged 1.2-6.4 pg/ dL

What are the symptoms of low testosterone in men?

Low testosterone levels in men can cause the following symptoms:

• Decreases in spontaneous erections
• Decreases in nighttime erections and erection rigidity
• Decreases in libido
• Orgasmic disorders
• Reductions in testicular volume/ size 
• Fatigue
• Lethargy
• Reductions in pubic hair and armpit hair (late sign)
• Depressed mood
• Irritability
• Increases in body fat
• Decreases in physical performance
• Decreases in muscle mass
• Reductions in endurance
• Weight loss and weight gain are both possible, as low testosterone may lead to reduced appetite, while simultaneously increasing fat accumulation (Sizar et al., 2023)

Other manifestations associated with low testosterone include reported reductions in quality of life, reductions in activity levels, and decreases in cognitive performance (Indirli et al., 2023). 

In addition to these symptoms, low testosterone is a risk factor for cardiovascular disease (Sizar et al., 2023).  

Even more concerning, low testosterone is linked to higher mortality in men, even when controlling for obesity, age, and lifestyle (Smith et al., 2021).  Testosterone replacement therapy (TRT) increases survival rates in hypogonadal men.  

What are low testosterone symptoms in women?

While women naturally have significantly less testosterone than men, testosterone levels across the lifespan of a woman actually run at about 10 times the level of estradiol in terms of nanograms/ dL of blood (Glaser & Dimitrakakas, 2013).  

Testosterone is the most abundant sex hormone in women throughout their lifespan (Glaser & Dimitrakakas, 2013).

Androgen receptors in women can be found in nearly every type of tissue (Glaser & Dimitrakakas, 2013).  

For women, testosterone deficiencies can lead to the following symptoms:

• Low libido
• Low energy
• Vaginal dryness
• Depression and anxiety
• Dry skin
• Brittle hair (Cleveland Clinic, 2023; Davis et al., 2015)

What causes low testosterone levels?

Low testosterone levels in men can be caused by a number of factors.  

Primary deficiencies in testosterone can be caused by problems with the testicles, such as: 

• Undescended testicles, 
• Diseases such as mumps orchitis and hemochromatosis
• Aging
• Autoimmune conditions
• Genetic syndromes like Klinefelter’s syndrome (a syndrome with two X chromosomes plus a Y chromosome) (Sizar et al., 2024; Kirby, 2015).

Secondary deficiencies in testosterone in men are caused by:

• Obesity
• Metabolic syndromes including: Insulin resistance, type II diabetes, high blood pressure
• Trauma to the testicles
• Surgical removal of testicles
• Stress  
• HIV
• Pituitary gland or hypothalamus disorders
• Pollutants from fungicides, pesticides, insecticides, including polychlorinated biphenyls (PCB’s)
• Decreased muscle tone (Sizar et al., 2024; Traish, 2014; Kirby, 2015; Lara et al., 2015; Goncharov et al., 2009)

For women, causes of low testosterone include:

• Menopause
• Removal of ovaries
• Addison’s disease
• Chemotherapy and radiation
• Estrogen therapy
• Hormone contraceptives
• Ovarian insufficiency
• PItuitary tumors
• Pollutants from fungicides, pesticides, insecticides, though PCB’s may have negligible effects in women in regards to testosterone levels
• Early menopause (before age 40) (Cleveland Clinic, 2023; Lara et al., 2015; Goncharov et al., 2006).

How can testosterone replacement help?

While lifestyle changes described below can improve testosterone to varying degrees, some of the problems associated with low testosterone (fatigue, depressed mood) can make adherence to the prescribed lifestyle regimens (weight loss, exercise) more difficult (Barbonetti, Adrea, & Francavilla, 2020).  

Some ways testosterone replacement can help those struggling with symptoms from low testosterone are outlined below.

Superior fat reduction

In a randomized, placebo-controlled clinical trial involving 100 obese male subjects, participants were put on a low calorie diet for 10 weeks, followed by a 46-week maintenance program. 

The intervention group were given testosterone injections weekly for 10 weeks while the control group received placebo injections. CT scans and DEXA scans were utilized to measure fat mass and lean body mass differences between the two groups.

The intervention group lost nearly exclusively visceral fat during the duration of the study, rapidly regaining all lost lean mass (such as muscle) following the end of the 10 week low calorie diet, whereas the control group did not regain their lost lean mass.  

This means that at the study’s end, the weight loss by the testosterone group was exclusively from fat reduction compared to the control group who lost both muscle/ lean tissue and fat (Ng Tang Fui et al., 2016).

Superior weight maintenance after weight loss

Not only did participants on testosterone replacement end up with more fat loss and muscle at the end of the weight loss portion of the study, the TRT treatment group also KEPT THE WEIGHT OFF whereas the control group started to regain weight (Ng Tang Fui et al., 2016).  

Higher activity levels and strength

Also interesting in the study, the TRT group boosted their grip strength significantly and had higher daily step counts of nearly 1000 steps more per day.  Further, non-sedentary time increased compared to the control group (Ng Tang Fui et al., 2016).  

More frequent sexual activity, and more sexual desire

In a placebo-controlled study of nearly 500 men over 65, with a baseline average testosterone level under 275 ng/ dL, testosterone gel treatment for 1 year increased sexual activity and sexual frequency significantly versus the placebo group (Cunningham et al., 2020).  

Further, as total testosterone, free testosterone, and estradiol levels increased, these corresponded to increases in sexual activity (Cunningham et al., 2020).  

Research involving a randomized-controlled trial of more than 700 men who were middle-aged with baseline testosterone under 300 ng/ dL found that testosterone replacement led to improvement in sex drive and a trend towards greater energy levels (Brock et al., 2016). 

Testosterone Replacement in Women

Testosterone replacement has been licensed for use in women in Germany and Australia for over 60 years (Glaser & Dimitrakakas, 2013).  Testosterone replacement is increasingly being used to help manage menopause symptoms in women, as opposed to being limited to treatment for low libido only (Glaser & Dimitrakakas, 2013).

Testosterone dosing in women can be adjusted to avoid side effects that concern women, such as facial hair (which occurs at higher doses of testosterone) (Glaser & Dimitrakakas, 2013).

Benefits of testosterone replacement in women may include the following (Glaser et al., 2012; Glaser & Dimitrakakas, 2013; Somboonporn et al., 2005):

• • Scalp hair regrowth (as seen in 63% of women with previous low testosterone and prior thinning hair after starting subcutaneous pellet placement for testosterone therapy. Non-responders were more likely to be iron-deficient, have low thyroid levels, or be obese.

• Improvements in cholesterol, blood sugar, and lean body mass

• • May be cardioprotective at normal levels & associated with lower heart disease risk

• Mental health:  testosterone replacement lowers levels of aggression, anxiety, and irritability, such as was demonstrated in one study in which 90% of women with these symptoms 

• Increased sexual satisfaction and increased frequency of sex

What are the risks of testosterone therapy? 

Testosterone therapy should not be used in the following circumstances (Barbonetti et al., 2020; Glaser, R., & Dimitrakakis, 2013): 

• Prostate cancer locally advanced or metastatic, presence of prostate nodules, or elevated PSA scores 
• Breast cancer locally advanced or metastatic
• Elevated hematocrit (greater than 48%)
• Severe heart failure, or heart attack or stroke in past 6 months
• Severe AND untreated sleep apnea 
• Men trying to have children in next 6 months

Testosterone replacement therapy can raise the levels of red blood cells produced by the body.  This is measured as hematocrit on a CBC.  In levels that are excessive, elevated red blood cells can contribute to the risk of heart attack and stroke.  

Hematocrit should be monitored routinely during treatment with testosterone.  

Prostate cancer screening using PSA testing is recommended during treatment.

Sleep apnea is temporarily worsened by testosterone replacement therapy.

Women reported facial hair growth at higher levels of testosterone therapy, though these effects can be reversed by lowering the dose.

What are natural options to raise testosterone?

Prior to committing to pharmacologic solutions for low testosterone, a person may be first interested in trying natural options to boost testosterone.

One of the most powerful interventions for men struggling with low testosterone?

Lose Weight

In a study of nearly 900 prediabetic men randomized into 3 groups, one with lifestyle interventions of a low fat diet and walking 150 minutes per week, one group receiving metformin, and one group receiving a placebo pill, the group doing the lifestyle changes improved their testosterone levels significantly.

On average, the men lost 17 lbs body weight in the lifestyle group.

At the start of the study prior to the lifestyle interventions, 1 in 5 men had testosterone levels below 300 ng/ dL.  After 1 year of the lifestyle intervention, this number dropped to nearly 1 in 10 men, meaning nearly half of those with low testosterone levels restored their testosterone back to normal levels above 300 ng/ dL after the lifestyle intervention and weight loss.

The link between weight loss and testosterone increases has been shown in a dose-like fashion in repeat studies (Endocrine Society, 2012; Corona et al., 2013). 

Exercise:  Aerobic & Resistance training 

Resistance training that is high volume, high-metabolic demand can cause acute increases in testosterone in men and not women (Vingren et al., 2010).  This effect diminishes with age.

Separately, a small study of 22 sedentary older (average age 62) obese men found that 6 weeks of moderate intensity exercise (such as brisk walking) for 150 minutes per week increased testosterone levels by 10% (Hayes et al., 2017).  

Testosterone further increased to a total of 17% higher after the participants did an additional 6 weeks of high-intensity interval training consisting of six 30 second sprints followed by 3 minutes of active recovery (Hayes et al., 2017).

Fenugreek for testosterone?

In a review of 6 studies, 4 of the 6 studies showed improvements in testosterone levels when men supplemented with commercial brand fenugreek extracts (Smith et al., 2021).

Five studies were randomized, double-blind, placebo-controlled trials and one was a randomized, double-blind, placebo-controlled crossover study (Smith et al., 2021).  

In one study, 250 mg of fenugreek extract was administered daily over a 12-week period for the intervention group versus a placebo group.  Men in the intervention group saw their total testosterone increase by approximately 23% versus the placebo group.

A separate study using 500 mg fenugreek extract produced an increase in total testosterone by nearly 7% and bioavailable testosterone by nearly 13%.  This was compared to a placebo group who actually saw their testosterone levels drop significantly during the same time period.

These were well designed studies but small in scope, with 30 or less study participants involving healthy young men.

A larger study with 120 participants over the course of 12 weeks focused on obese middle age and older men.  It found that total testosterone increased by 12% and free testosterone increased by about 10% in the intervention arm receiving 600 mg fenugreek.

The placebo group experienced decreases in testosterone during the same 12-week period. 

One 12-week study involving healthy young men found a nearly 100% increase in free testosterone, though total testosterone did not change between the two groups (Smith et al., 2021).

Safety:  fenugreek is believed to be safe in amounts used commonly in food, but its safety in larger doses is unknown.  Fenugreek can lower blood sugar levels significantly which may be of concern to diabetics on medicines that lower blood sugars.  

Reports of liver toxicity associated with use of fenugreek have been reported.  Pregnant women should avoid fenugreek.  More information can be found here (National Center for Complementary and Integrative Health, 2020).

Ashwagandha

In an analysis of research on ashwagandha, 3 out of 4 studies showed a benefit of ashwagandha supplementation for testosterone (Smith et al., 2021).

Three studies used a randomized, double-blind, placebo-controlled study design, and 1 study used a randomized, double-blind, placebo-controlled, crossover study design (Smith et al., 2021).

In one of the trials, after 8 weeks of placebo treatment, men were placed on ashwagandha for another 8 weeks.  Testosterone was approximately 17% higher at the end of the treatment with ashwagandha than in the group who had tested at the end of 8 weeks of placebo treatment (Smith et al., 2021).  

The formula used in this study was standardized to 21 mg of withanolide glycosides. 

Another study with KSM-66 brand ashwagandha 600 mg found a 15% increase in testosterone compared to a placebo group (who saw an approximate 3% increase) after 8 weeks of treatment.  

A third study found a 17% increase in testosterone after 90 days of treatment with 675 mg KSM-66 brand ashwagandha compared to a 4% increase in the placebo group.  

The one study that showed no statistically significant effect utilized a 250 mg ashwagandha extract dose.  Both the placebo and treatment group testosterone increased but the difference was not large enough to be considered significant (Smith et al., 2021).  

These studies were all smaller studies ranging from 47-60 participants (Smith et al., 2021).  Age ranges were 18 to 70 years old.

Safety:  long term studies on ashwagandha are lacking.  It may be safe for 30 days according to the National Center for Complementary and Integrative Health (2023).  There are rare reports of liver injury.  Pregnant women and persons with autoimmune disorders should avoid ashwagandha.  More information is available here.

Coleus forskohlii (forskohlii)

A study that was a double-blinded, placebo-controlled, randomized trial lasting 12-weeks found that 500 mg of forskohlii increased testosterone by 13.6% compared to a placebo group (Smith et al., 2021).

Safety:  forskohlii can cause low blood pressure, worsening of cysts in kidney for those with polycystic kidney disease, heart rate increases, and stomach distress in some people.  To learn more, click here.

What herbs likely DO NOT work for increasing testosterone?

While research continues, the following herbs were studied and found to be largely inconsistent / or completely ineffective at increasing testosterone in humans (Smith et al., 2021):

• Tribulus terrestris (1 study showed significant positive effects after 3 months, but lacked analysis against a control group, 3 studies showed no effect between placebo and tribulus treatment groups)
• Maca 
• Asian ginseng (1 study showed positive effects while 5 studies showed no effect)
• Rhodiola rosea
• Musali
• Garcinia
• Reishi
• Stinging nettle root 
• Eurycoma longifolia (longjack)
• Cordyceps

How Lancaster Wellness can help

Lancaster Wellness can help clients who may be struggling with symptoms of low testosterone in the following ways:

• Testing testosterone levels and ongoing monitoring when appropriate
• Symptom evaluation
• Testosterone replacement therapy for men AND women can be done in office with a quick procedure requiring no down time
• Weight loss program averages 20-40 lbs in 3 months::  research affirms that losing excess weight can significantly increase testosterone levels 

Written by Donovan Carper MSN, RN, CPT, CHC

References

American men. Environmental health perspectives, 117(9), 1454–1460. https://doi.org/10.1289/ehp.0800134 

Baqer Ali, E., Alhamza, A., Zaboon, I. A., Alidrisi, H. A., & Mansour, A. A. (2023). Fasting Versus Non-Fasting Total Testosterone Levels in Women During the Childbearing Period. Cureus, 15(2), e35462. https://doi.org/10.7759/cureus.35462

Barbonetti, A., D’ Andrea, S., & Francavilla, S. (2020). Testosterone replacement therapy. Andrology. Retrieved from https://onlinelibrary.wiley.com/doi/10.1111/andr.12774

Brock, G., Heiselman, D., Maggi, M., Kim, S. W., Rodríguez Vallejo, J. M., Behre, H. M., … Kinchen, K. (2016). Effect of Testosterone Solution 2% on Testosterone Concentration, Sex Drive and Energy in Hypogonadal Men: Results of a Placebo Controlled Study. Journal of Urology, 195(3), 699–705. https://doi.org/10.1016/j.juro.2015.10.083 (Original work published March 1, 2016) 

Corona, G., Rastrelli, G., Monami, M., Saad, F., Luconi, M., Lucchese, M., Facchiano, E., Sforza, A., Forti, G., Mannucci, E., & Maggi, M. (2013). Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis. European journal of endocrinology, 168(6), 829–843. https://doi.org/10.1530/EJE-12-0955  

Cunningham, G. R., Stephens-Shields, A. J., Rosen, R. C., Wang, C., Bhasin, S., Matsumoto, A. M., Parsons, J. K., Gill, T. M., Molitch, M. E., Farrar, J. T., Cella, D., Barrett-Connor, E., Cauley, J. A., Cifelli, D., Crandall, J. P., Ensrud, K. E., Gallagher, L., Zeldow, B., Lewis, C. E., Pahor, M., … Snyder, P. J. (2016). Testosterone Treatment and Sexual Function in Older Men With Low Testosterone Levels. The Journal of clinical endocrinology and metabolism, 101(8), 3096–3104. https://doi.org/10.1210/jc.2016-1645 

Davis, Susan R et al. (2015). The Lancet Diabetes & Endocrinology, Volume 3, Issue 12, 980 – 992

Dhindsa, S., Miller, M. G., McWhirter, C. L., Mager, D. E., Ghanim, H., Chaudhuri, A., & Dandona, P. (2010). Testosterone concentrations in diabetic and nondiabetic obese men. Diabetes care, 33(6), 1186–1192. https://doi.org/10.2337/dc09-1649

Endocrine Society. (2012, June 25). Overweight men can boost low testosterone levels by losing weight. ScienceDaily. Retrieved October 25, 2024 from www.sciencedaily.com/releases/2012/06/120625124914.htm 

Glaser, R., & Dimitrakakis, C. (2013). Testosterone therapy in women: myths and misconceptions. Maturitas, 74(3), 230–234. https://doi.org/10.1016/j.maturitas.2013.01.003 

Glaser, R. L., Dimitrakakis, C., & Messenger, A. G. (2012). Improvement in scalp hair growth in androgen-deficient women treated with testosterone: a questionnaire study. The British journal of dermatology, 166(2), 274–278. https://doi.org/10.1111/j.1365-2133.2011.10655.x 

Goncharov, A., Rej, R., Negoita, S., Schymura, M., Santiago-Rivera, A., Morse, G., Akwesasne Task Force on the Environment, & Carpenter, D. O. (2009). Lower serum testosterone associated with elevated polychlorinated biphenyl concentrations in Native 

Hayes, L. D., Herbert, P., Sculthorpe, N. F., & Grace, F. M. (2017). Exercise training improves free testosterone in lifelong sedentary aging men. Endocrine connections, 6(5), 306–310. https://doi.org/10.1530/EC-17-0082 

Hayes, L. D., Herbert, P., Sculthorpe, N. F., & Grace, F. M. (2017). Exercise training improves free testosterone in lifelong sedentary aging men. Endocrine connections, 6(5), 306–310. https://doi.org/10.1530/EC-17-0082 

Indirli, R., Lanzi, V., Arosio, M., Mantovani, G., & Ferrante, E. (2023). The association of hypogonadism with depression and its treatments. Frontiers in endocrinology, 14, 1198437. https://doi.org/10.3389/fendo.2023.1198437

Kirby, M. (2015). Testosterone deficiency. Practice Nurse, 45(11), 32–36.

Lara, L. A., Duarte, A. A., Reis, R. M., Vieira, C. S., & Rosa-e-Silva, A. C. (2012). Endocrine disrupters: potential risk factors affecting sexual function in both men and women. The journal of sexual medicine, 9(3), 941–942. https://doi.org/10.1111/j.1743-6109.2011.02596.x 

National Center for Complementary and Integrative Health. (2023). Ashwagandha. Retrieved from https://www.nccih.nih.gov/health/ashwagandha 

National Center for Complementary and Integrative Health. (2020). Fenugreek. Retrieved from https://www.nccih.nih.gov/health/fenugreek 

Ng Tang Fui, M., Prendergast, L. A., Dupuis, P., Raval, M., Strauss, B. J., Zajac, J. D., & Grossmann, M. (2016). Effects of testosterone treatment on body fat and lean mass in obese men on a hypocaloric diet: a randomised controlled trial. BMC medicine, 14(1), 153. https://doi.org/10.1186/s12916-016-0700-9 

Sizar O, Leslie SW, Schwartz J. Male Hypogonadism. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532933/ 

Smith, S. J., Lopresti, A. L., Teo, S. Y. M., & Fairchild, T. J. (2021). Examining the Effects of Herbs on Testosterone Concentrations in Men: A Systematic Review. Advances in nutrition (Bethesda, Md.), 12(3), 744–765. https://doi.org/10.1093/advances/nmaa134 

Somboonporn, W., Bell, R. J., & Davis, S. R. (2005). Testosterone for peri and postmenopausal women. Cochrane Database of Systematic Reviews. Retrieved from https://doi.org/10.1002/14651858.CD004509.pub2 

Traish A. M. (2014). Testosterone and weight loss: the evidence. Current opinion in endocrinology, diabetes, and obesity, 21(5), 313–322. https://doi.org/10.1097/MED.0000000000000086

Vingren, J. L., Kraemer, W. J., Ratamess, N. A., Anderson, J. M., Volek, J. S., & Maresh, C. M. (2010). Testosterone physiology in resistance exercise and training: the up-stream regulatory elements. Sports medicine (Auckland, N.Z.), 40(12), 1037–1053. https://doi.org/10.2165/11536910-000000000-00000