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7 low testosterone symptoms: Get small daily joys back!

Low testosterone symptoms

Written by

Alexander Grant, MD, PhD: Urologist & Men’s health advocate

in

Low testosterone can dull energy, drive, and mood. Treating a true deficiency often helps men re-engage with work, family, and hobbies.

“Men often look only at libido. The real low testosterone symptoms: fewer morning erections, low drive, fatigue, weight gain, and slower recovery. When testosterone is truly low, treating it can bring daily life back into focus.”

Alexander Grant, MD, PhD — Urologist and researcher specializing in men’s reproductive health and hormone balance

The relationship

Low testosterone means a sustained reduction in circulating testosterone with symptoms that affect daily life. Doctors call this hypogonadism, which is testosterone deficiency with consistent lab evidence and clinical signs [1]. The most common question is whether low testosterone explains fatigue, motivation loss, and low libido.

Randomized trials in 2016 and 2017 showed that testosterone therapy can
improve sexual function and modestly improve vitality and mood in older men who meet diagnostic criteria [2,3]. Those trials also found benefits for anemia correction and bone density when levels are restored toward the mid-normal range [4,5].

The key is matching the pattern of symptoms to accurate testing. One isolated number is not enough. Timing of the blood draw, binding proteins, and other health conditions all influence the result [1].

How it works

The brain–testis loop

The hypothalamic–pituitary–testicular axis is the control loop that drives testosterone production. The brain releases GnRH, which triggers LH and FSH from the pituitary; LH then stimulates the testes to make testosterone. Testosterone feeds back to the brain to keep the loop in balance [6].

Total vs free testosterone

Most testosterone travels attached to proteins in blood, mainly sex hormone–binding globulin (SHBG). Only a small “free” fraction can enter cells and do the work. When SHBG is high or low, the total number can be misleading, so clinicians calculate or measure free testosterone to get the full picture [7,8].

Testosterone, estradiol, and balance

The enzyme aromatase converts some testosterone to estradiol. Estradiol helps with libido and fat regulation in men, and too little estradiol can hurt sexual function and body composition. Human experiments that blocked aromatase confirmed this shared role [9,10].

Circadian rhythm and timing

Testosterone peaks in the morning and drifts lower over the day. Morning samples are preferred, and repeat tests on different days reduce false results [11,12]. Thresholds used in practice: men with symptoms are most likely to benefit from treatment when total testosterone is below 350 ng/dL (≈12 nmol/L). If the total is borderline, measure free testosterone; values below 100 pg/mL (≈10 ng/dL) support the diagnosis [13].

Conditions linked to it

Extra body fat and metabolic syndrome often coexist with low testosterone. In many men, weight gain and insulin resistance lower testosterone by increasing aromatase activity and changing SHBG levels [14]. Treating the weight and the hormones can work together.

Obstructive sleep apnea can reduce testosterone and worsen daytime fatigue. Treating the apnea helps sleep and cardiometabolic risk, though it may not raise testosterone by itself [15,18].

Long term opioid therapy can suppress the brain’s signal to the testes and lead to very low testosterone, called opioid-induced androgen deficiency [16].

Symptoms and signals

  • Low libido and fewer morning erections.
  • Erectile difficulties despite stimulation.
  • Persistent fatigue and lower stamina.
  • Motivation loss for work and hobbies.
  • Depressed mood or irritability.
  • Brain fog and low T: slower recall and focus.
  • Slower recovery from workouts or injury.
  • More body fat, especially at the waist.
  • Less muscle or reduced strength.
  • Hot flashes or increased sweating at rest.
  • Poor sleep and snoring risk.
  • Reduced shaving frequency or body hair.

What to do about it

Here is a simple plan that respects the evidence and your time.

1) Test correctly. Schedule two morning blood draws on different days. Measure total testosterone with a reliable assay. Add free testosterone if total is borderline or SHBG is abnormal. Check LH, FSH, and prolactin to define the cause. Consider estradiol, SHBG, and a complete blood count. Follow major guidelines for timing and repeats [1,12,13].

2) Use a layered treatment approach. Start with the basics that can raise testosterone and improve symptoms: structured weight loss, resistance training, and better sleep. Weight reduction programs and bariatric pathways often raise testosterone and improve energy and metabolic health [17]. Treat sleep apnea for health outcomes, knowing testosterone may not change much [18].

If you and your clinician confirm persistent low testosterone with symptoms, discuss testosterone therapy. Expect clearer improvements in sexual function, with smaller effects on vitality and mood, as shown in trials from 2016 to 2017 [2,3]. Therapy can correct anemia and increase bone density in qualified men [4,5]. In men at risk for diabetes, a 2021 randomized trial found that adding testosterone to lifestyle support reduced progression to type 2 diabetes over two years [19].

Review safety and monitoring. Watch for erythrocytosis, which means too many red blood cells; this is the most consistent lab adverse effect in trials [20]. Expect small rises in PSA, which is a prostate protein used for screening; large or rapid changes require evaluation [21]. A 2023 cardiovascular outcomes trial found testosterone was noninferior to placebo for major adverse cardiac events in properly selected men with documented deficiency [22]. Do not use testosterone if you plan near-term fertility. External testosterone can suppress sperm production; recovery after stopping is possible but not guaranteed [23,24].

3) Monitor and adjust. Recheck symptoms and labs after dose changes, then at regular intervals. Track hematocrit, PSA as appropriate for age and risk, and testosterone levels to make sure you are in the therapeutic range and not overtreating [1,12].

Myth vs Fact

  • Myth: Low testosterone symptoms are only about sex.
    Fact: Energy, mood, and motivation often change as well.
  • Myth: Testosterone builds muscle overnight.
    Fact: Strength gains require training and time.
  • Myth: Testosterone always harms the heart.
    Fact: Modern outcomes data show no excess in major cardiac events in properly selected men on therapy [22].
  • Myth: Over-the-counter boosters replace therapy.
    Fact: No robust evidence shows they correct the deficiency.
  • Myth: Therapy cures every “brain fog” complaint.
    Fact: Mood and cognition responses vary and are usually modest [3,25].

Bottom line

Low testosterone symptoms reach beyond the bedroom. The pattern spans libido, energy, mood, and recovery. Accurate testing and a structured plan can help. Many men do best when weight, sleep, and health risks are addressed first, and testosterone is added only when deficiency is clear and persistent. The goal is not a bigger number. The goal is a better day.

References

  1. Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018;200(2): 423–432. PMID: 29601923.
  2. Snyder PJ, Bhasin S, Cunningham GR, et al. Effects of Testosterone Treatment in Older Men. N Engl J Med. 2016;374(7):611–624. PMID: 26886521.
  3. Snyder PJ. Lessons From the Testosterone Trials. Endocr Rev. 2018;39(3):369–386. PMID: 29522088.
  4. Roy CN, Snyder PJ, Stephens-Shields AJ, et al. Association of Testosterone Levels With Anemia in Older Men. JAMA Intern Med. 2017;177(4):480–490. PMID: 28241237.
  5. Snyder PJ, Kopperdahl DL, Stephens-Shields AJ, et al. Effect of Testosterone Treatment on Volumetric Bone Density and Strength in Older Men With Low Testosterone. JAMA. 2017;317(7):717–727. PMID: 28241231.
  6. Acevedo-Rodriguez A, Laconi M, et al. Emerging insights into HPG axis regulation and interaction with stress signaling. J Neuroendocrinol. 2018;30(10):e12590. PMID: 29524268.
  7. Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple
    methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84(10):3666–3672. PMID:10523012.
  8. Narinx J, Van Nieuwpoort IC, Ronde W de. Free testosterone in men: reference ranges, pitfalls and best practice. Front Endocrinol (Lausanne). 2022;13:1015613. PMCID: PMC11803068.
  9. Swislocki A, Csako G. The Testosterone–Estradiol ratio in men.
    Front Endocrinol (Lausanne). 2024;15:1423035. PMCID: PMC12257316.
  10. Finkelstein JS, Lee H, Burnett-Bowie SA, et al. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med. 2013;369(11):1011–1022. PMID: 24024838.
  11. Crawford ED, Barqawi AB, O’Donnell C, Morgentaler A. The association of time of day and serum testosterone in men being investigated for prostate disease. BJU Int. 2015;116(4):680–685. PMID: 26360789.
  12. Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744. PMID: 29562364.
  13. Salonia A, Bettocchi C, Boeri L, et al. European Association of Urology Guidelines on Sexual and Reproductive Health—2021 Update: Male
    Sexual Dysfunction. Eur Urol. 2021;80(3):333–357. PMID: 34183196.
  14. Fui MN, Dupuis P, Grossmann M. Lowered testosterone in male obesity: mechanisms, morbidity and management. Asian J Androl. 2014;16(2):223 231. PMID: 24407187.
  15. Kim SD, Cho KS. Obstructive Sleep Apnea and Testosterone Deficiency. World J Mens Health. 2018;36(3):239–247. PMCID: PMC6305865.
  16. Smith HS, Elliott JA. Opioid induced androgen deficiency (OPIAD). Pain Physician. 2012;15(3 Suppl):ES145–ES156. PMID: 23018668.
  17. Okobi OE, Oyelade BO, Akinsola AO, et al. Influence of Weight Loss on Testosterone Levels: A Review of Pathophysiology and Clinical Outcomes. Nutrients. 2024;16(8):1240. PMCID: PMC10886777.
  18. Cignarelli A, Giagulli VA, et al. The complex relation between obstructive sleep apnea syndrome, hypogonadism and testosterone replacement therapy. Front Endocrinol (Lausanne). 2019;10:691. PMCID: PMC6710495.
  19. Wittert GA, et al. Testosterone treatment to prevent or revert type 2
    diabetes in men enrolled in a lifestyle program (T4DM). Lancet Diabetes Endocrinol. 2021;9(1):32–45. PMID: 33338415.
  20. Ponce OJ, Spencer-Bonilla G, Alvarez-Villalobos N, et al. The efficacy and adverse events of testosterone replacement therapy in hypogonadal men: a systematic review and meta-analysis of randomized, placebo-controlled trials. J Clin Endocrinol Metab. 2018;103(5):1745–1754. PMID: 29562341.
  21. Cunningham GR, Stephens-Shields AJ, Rosen RC, et al. Prostate-Specific Antigen Levels During Testosterone Treatment of Hypogonadal Older Men. J Clin Endocrinol Metab. 2019;104(12):6238–6246. PMCID: PMC6823728.
  22. Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy. N Engl J Med. 2023;389(13):1174–1187. PMID: 37326322.
  23. Crosnoe LE, Kim ED, Perkins AR, et al. Exogenous testosterone: a preventable cause of male infertility. Transl Androl Urol. 2013;2(2):106–113. PMCID: PMC4708215.
  24. McBride JA, Carson CC, Coward RM. Recovery of spermatogenesis following testosterone replacement therapy or anabolic-androgenic steroid use. J Urol. 2016;195(6):1500–1506. PMCID: PMC4854084.
  25. Walther A, Breidenstein J, Miller R. Association of Testosterone Treatment With Alleviation of Depressive Symptoms in Men: A Meta-analysis of Randomized Clinical Trials. JAMA Psychiatry. 2019;76(1):31–40. PMID: 30427999.

 

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