The testosterone trap: Why your problem might not be ‘low T'

Yahoo

4 hours ago

Dr. Jamin Brahmbhatt is a urologist and robotic surgeon with Orlando Health and an assistant professor at the University of Central Florida's College of Medicine.
You're feeling unusually tired and sad, and your interest in sex has dropped off.
That's no fun. If you're a guy, you may be thinking you have low testosterone.
Wait a minute. Don't we all experience some or all of these symptoms at one time or another? After a late night out, a stressful workweek or even just a bad night's sleep, it's common to feel tired, irritable or unmotivated.
But I know my patients want to eliminate low testosterone as the source, so I often start with a survey called the Androgen Deficiency in the Aging Male, or ADAM, questionnaire. Take a minute to see how many 'yes' answers you collect.
Do you have a decrease in your libido, or sex drive?
Do you have a lack of energy?
Do you have a decrease in strength and/or endurance?
Have you lost height?
Have you noticed a decreased enjoyment of life?
Are you sad and/or grumpy?
Are your erections less strong?
Have you noticed a recent deterioration in your ability to play sports?
Are you falling asleep after dinner?
Has there been a recent deterioration in your work performance?
If you answered 'yes' to question 1 or 7, or to more than three questions overall, you might have low testosterone, according to this questionnaire.
Or maybe you don't. These questions and answers are the start of this journey, not the end. While these questions can be helpful, they're broad enough to describe common life experiences we all face.
As a urologist specializing in men's health, I often see patients convinced they have low testosterone based solely on these symptoms, only to find their testosterone levels are perfectly within range (more on those levels below).
Even as an expert in the field, I have also run to get my testosterone checked — only to realize my symptoms were due to poor sleep habits rather than a true hormone deficiency.
A quick note before we dive deeper: I understand this can be a sensitive topic. The information provided here isn't truth for every man. Many patients come to my clinic frustrated and seeking clear answers.
Even within the medical community, there's significant debate about how to diagnose and manage 'low T.' My intention isn't to discount or downplay your concerns but rather to provide perspective and education, and to help you make informed decisions with your health care provider.
Diagnosing low testosterone can be tricky, even for urologists like me. That said, a total testosterone level below 300 ng/dL (nanograms per deciliter) is recommended as the cutoff for diagnosing testosterone deficiency, according to the latest American Urological Association guidelines.
But here's the tricky part: Labs don't always agree on what they consider normal, leading to confusion for patients and medical professionals. Take two of the most popular labs in the United States — Quest Diagnostics and LabCorp — as examples. Quest lists a normal testosterone range of 250 to 1100 ng/dL, while LabCorp uses 264 to 916 ng/dL. This means a level of 260 ng/dL might be flagged as 'low' by one lab but 'normal' at another. That's why most American urologists rely on the AUA guidelines, bearing in mind that every patient's situation is different.
To ensure accuracy, guidelines recommend checking testosterone levels twice — on two separate mornings, ideally between 7 a.m. and 10 a.m. Why so early? Because that's when your fluctuating testosterone is at its peak, making it the best time to gauge your true levels. The first peak occurs in the morning, and the second peak (not as high as the morning) occurs in the afternoon, with your testosterone level gradually dropping by the end of the day. Lab companies also base their 'normal' reference ranges on the assumption that your testosterone tests are done during these specific morning hours.
Additionally, the clinical diagnosis of testosterone deficiency relies not only on lab numbers but also on the presentation of symptoms such as low energy, reduced libido, loss of muscle mass or mood changes.
When we start testosterone therapy, the goal is typically to raise testosterone levels into the range of about 450 to 600 ng/dL, which is considered the 'middle tertile' for most laboratory reference ranges. That middle third is the 'sweet spot' in which most men experience relief or resolution of their symptoms, without exceeding levels that could cause unwanted risks or side effects. It can take months to find the right and safe dose for a patient.
Further adding to our dilemma as doctors, testosterone sensitivity varies from man to man. This variation may relate to genetic factors, according to research, including the sensitivity of your testosterone receptors. That's why a man with a testosterone level of 400 ng/dL may feel great, while another at the same level may experience countless symptoms.
Currently, testing testosterone sensitivity isn't something readily available. The hope, however, is to someday have a routine test that helps us better personalize testosterone replacement therapy.
Diagnosing and treating low testosterone is still very much a work in progress, with ongoing debates among experts. However, other medical issues that mimic low testosterone symptoms are more straightforward, backed by strong research.
Many men whose testosterone lab results are completely normal still experience persistent symptoms. Often, these issues have more to do with lifestyle or other medical factors rather than testosterone itself.
In 2025, many medical professionals, including myself, have become more open to testosterone replacement therapy as newer research has disproven some of the significant risks previously feared, such as concerns over prostate cancer or cardiovascular disease.
Still, testosterone replacement isn't the right choice for everyone, and there could be other medical conditions that mimic the same symptoms that should be the primary focus of your (and your doctor's) investigation.
In my own experience, poor sleep has frequently been the reason behind feeling tired and irritable. Sleep is essential for hormone regulation, mood stability and overall health. Chronic sleep deprivation can lead to fatigue, mood swings, low libido and difficulty concentrating, according to the National Institutes of Health. Those are all symptoms that mimic what we see with low testosterone.
A common cause of poor sleep is obstructive sleep apnea, a condition where breathing repeatedly stops and starts when you're trying to get a good night's rest. Sleep apnea can dysregulate your hormonal balance and lower your testosterone levels. The use of continuous positive airway pressure, or CPAP, machines has been shown to improve sleep quality, improve testosterone and alleviate symptoms.
I started using an activity tracker 24/7, which quickly identified my own sleep issues. Eliminating late-afternoon caffeine and swapping evening screen time for reading before bed significantly boosted my sleep quality, energy levels and overall mood — without any hormone therapy. My own small changes led to big improvements.
Chronic stress may make you feel like your testosterone is low. Elevated cortisol, your body's primary stress hormone, can temporarily suppress testosterone production, causing symptoms identical to testosterone deficiency, especially reduced libido and fatigue.
Diet and exercise also play crucial roles. Studies have shown that testosterone levels in men have significantly declined over recent decades. Experts believe this decline is closely linked to rising obesity rates, chronic stress and increasingly sedentary lifestyles. Many of my own patients report dramatic improvements in energy, mood and libido simply by losing weight, eating healthier and staying physically active.
Several medical conditions can mimic symptoms attributed to low testosterone. Low thyroid or vitamin deficiencies (vitamin D or vitamin B12) can cause fatigue, mood changes and low libido. Diabetes or heart disease commonly cause fatigue and sexual dysfunction. Many patients initially thinking they have testosterone deficiency improve significantly after addressing these (and other) medical conditions without any need for hormonal treatment.
Another common scenario involves erectile dysfunction. Many patients mistakenly attribute their decreased libido or lack of sexual interest to low testosterone. In most cases, frustration and anxiety about sexual performance led to psychological withdrawal, decreasing sexual desire and confidence.
There is a small percentage of men whose erectile dysfunction genuinely stems from low testosterone levels. In these cases, testosterone replacement therapy might help. However, in my personal experience, replacing testosterone alone often leads to more frustration: Men may experience higher libido, yet still face difficulty achieving or maintaining an erection.
That's why it's usually better to treat ED directly — often with affordable generic medications like tadalafil or sildenafil — to restore sexual confidence and performance. These medications, once costing nearly $40 per pill, are now often as affordable as $40 for a three-month supply, providing a practical and reliable solution for most men.
The number of men receiving testosterone tests and prescriptions has nearly tripled in recent years, according to the 2024 American Urological Association guidelines.
Up to 25% of men starting testosterone therapy were never tested before starting treatment, the AUA noted. Nearly half never have their testosterone rechecked after initiating treatment. Up to a third of men receiving testosterone therapy don't meet the official clinical criteria for testosterone deficiency.
Meanwhile, many men who would benefit from testosterone replacement therapy remain untreated because of lingering concerns among health care providers about potential prostate cancer or cardiovascular risks — concerns not strongly supported by current evidence found in the AUA guidelines and recent research published in the New England Journal of Medicine. Additionally, men who skip routine screenings or simply don't feel comfortable openly discussing their symptoms also miss out on the treatment and relief they could experience.
This all feels like a 'chicken or egg' scenario: Will starting testosterone therapy motivate men to exercise more and manage their health better, or should we first address lifestyle and health issues before considering hormone therapy? These complexities highlight the importance of personalized conversations between you and your health care provider.
In my practice, I always focus first on lifestyle: Are you getting quality sleep? How high are your stress levels? Are you physically active? How healthy are your personal relationships? By tackling these areas first, many of my patients see noticeable improvement without falling into the testosterone trap.
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