There are a lot of people taking testosterone, men and women. Yet, the diagnosis and treatment of low testosterone is tricky and a controversial topic:
Symptoms are vague (fatigue, low sex drive), and thus, potentially attributable to many other causes.
There is a wide range of normal testosterone values within an individual and between individuals.
When reasonable doses of testosterone are used, the positive effects are subtle to detect.
Because we have no study lasting longer than a year, potential side effects, like heart disease and cancer, are difficult to rule out.
There are certainly more questions than answers, and even less is known in women. (I have covered the topic of 'low T' in the past). Despite this uncertainty, the business model of the Hormone Doctor, the Hormone Clinic, or the Longevity Center is to convince you otherwise. Their first step is to demonstrate that your levels are low with a lab test. Whether they are actually low, making them appear low is easily accomplished by taking advantage of your natural daily variation of testosterone, and using their lab of choice.
Natural variation of testosterone
Testosterone levels dramatically drop as the day goes on (see diagram below). For example, a man with a level of 750 ng/dL in the morning can drop down to as low as 500 ng/dL in the afternoon. Eating lowers testosterone levels even further; a single meal will decrease testosterone by 25%. If a hormone clinic wants you to have a low level they need only to set up the appointment and blood draw after lunch.
Their lab of choice
Another trick of the Hormone Clinics is to send your testosterone sample to their in-house lab or a small private lab. They will insist that their lab, “specializes in hormones, and is better than the BIG labs”. In reality, measuring hormone levels accurately is very tricky. It requires very expensive and delicate equipment like a mass spectrometer and liquid chromatography. Determining proper reference ranges is even more tricky. It requires complex statistical analysis and very large sample sizes. Because of this, the CDC developed a hormone standardization program (HoSt). Participating labs that adhere to these standards can ensure more reliable results. In-house labs and small private labs that do not are more likely to generate unreliable results, and left to their own devices, bias results and reference ranges to make your testosterone levels look low.
Let me illustrate what I mean by changing reference ranges. A patient of mine went to the 4Ever Young anti-aging clinic in Boca Raton. He was 58 years old at the time and his measured testosterone in their lab was 730 ng/dL (see below, circled in purple). This is at the upper end of normal in most labs and an excellent number for any age. Yet, according to their lab, he has low testosterone. Their reference range for optimal testosterone is set between 1000 ng/dL and 1200 ng/dL. To make sure this was not a calibration issue I remeasured his testosterone with my HoSt certified lab. I got the same result, 700 ng/dL. Therefore, the 4Ever Young lab measured the testosterone level accurately, they just altered the reference range. Quite disturbing since 99.9% of the population would be deemed “low testosterone” with this reference range. How convenient for a clinic that sells testosterone. A great example of conflict of interst and medicalization.
A willing participant in this deception
But, at the end of the day, some patients are willing participants in this deception. They almost want the diagnosis of “low T”. It is a quick and easy answer to explain their problems. Unfortunately, most of them probably had normal levels to begin with, and thus, probably climb to “supraphysiologic” levels when the clinic initiates treatment. Levels significantly above the healthy normal. Levels likely to cause some long term harm. They are only kidding themselves when they claim, “I am just bringing my levels to healthy normal values”.
For others, the goal of going to these clinics IS to get supraphysiologic levels. The hormone clinics are just a legal route of getting “steroids“, instead of getting them in a dirty unmarked bottle from the guy at the gym.
The take home message
Don’t bother checking your testosterone levels if you feel fine. Most of the evidence points in the direction that testosterone is not a longevity hormone. If a man had his testicles removed at birth, he would probably live a little longer. If you are interested and want to check your testosterone levels:
Make sure it is a fasted sample drawn in the morning.
Make sure it is sent to a reputable lab that complies with the HoSt program.
If the levels are low, repeat the measurement.
If they are still low, clean up your life: get more sleep, reduce stress, reduce alcohol and drugs, clean up your diet, lose weight, exercise moderately.
Then repeat the measurement.