STEP 1. One philosophy that I think holds up well in the research is the concept of replacement. By that I mean, there are hormones and key enzymes and antioxidants that should be replaced to youthful levels if missing in order to optimize general physicial and mental health. Examples abound and include many hormones, antioxidants such as CoQ10 and digestive enzymes as well. Again, the idea of replacement means, by definition, to youthful levels and not to the supraphysiological levels of steroid users or supplement megadosers.
One reason that I am a big believer in replacment as a general health philosophy is that HRT (testosterone therapy) has been a transforming life experience for me: when I got on testosterone cypionate injections which took my testosterone up into the 900-1000 ng/dl average range I noticed that for the first time in my life I had morning erections! I also noticed that the mild depression that I had struggled with my entire adult life vanished overnight. (You can read My Personal Health and HRT Story for the many bumps in my journey.)
Now you and your doctor will have to decide if you subscribe to this kind of replacement philosophy, but, if so, then this leads to the first step of what I call My Peak Testosterone Program:
STEP 1: TESTOSTERONE and ESTRADIOL
a) Assess Your Symptoms. The first step of my personal program is to examine your testosterone symptoms. Let's look at the very common symptoms of low testosterone:
Now there are many other what I would call more "minor"symptoms, such as poor workout recovery, decreased facial hair, poor sleep, "hot flashes", etc. But the above list are the most common and the most debilitating from what I have seen. (There are some dangerous side effects of low testosterone such as anemia and bone loss, but most men have not been tested for these initially.) In my case, I had ALL of the above symptoms when I hit my late 40's, but you may have only one or two. I finally asked my doctor about this and got tested after years of suffering.
CAUTION: Notice that all of these seven of the signs of low T can have many other causes. There is no guarantee that testosterone is the root cause.
b) Testosterone and Estradiol Testing. If you have any of the above symptoms, get your testosterone and estradiol (ultrasensitive) pulled. It's inexpensive and, even if you are not low T, you've got a nice baseline for the future. If you can afford it, pull free testosterone and/or SHBG as well.
c) Choose a Hypogonadism Threshold: Most of the labs still consider ~280 ng/dl to be hypogonadal. The one exception is LabCorp which is currently using ~350 ng/dl from what I understand. Based on what I have seen, men can experience very significant low testosterone symptoms below about 400 ng/dl and some younger men seem to feel it at around 500 ng/dl. You are your doctor have to choose a number where you feel it is "clinical". For me the number where I seemed to experience severe symptoms was around 350.
d) Choose an Estradiol Range. Most of the HRT clinics and anti-aging physicians try to get their patients in the 20-30 pg/ml range from what I have seen. And the reason is simple: generally their patients feel better in that area. The other reason is that there is evidence that this is the safest area based on some research summarized in this Life Extension article.
Now I have seen some doctors go down to about 15 and some up to 35 pg/ml. But the concept is this: low and high estradiol can affect sexual and mental function just as much as low testosterone and are likely also dangerous to your long term health just like low testosterone. (A recent study confirmed the former. )
What If My Physician Will Not Even Test Me? Most regular doctors have limited knowledge of testosterone and very few understand the importance of estradiol. Because of this, sometimes a man cannot even get the basic testing that he needs which is a grave injustice in my opinion. Been there! Remember: most physicians are good-hearted people, but they are constrained by insurance companies and their physician partners to hold down costs, and so you will generally receive very limited lab work under managed care. However, the good news is that, at least here in the U.S., the medical establishment has not been able to override our ability to do some basic testing on our own and I have some of the options that Peak Testosterone Forum members have used in this link on Testosterone Labs. (I have no affiliation with any of them.)
e) Testosterone Treatment. If your total testosterone is below the hypogonadism threshold above, then you and your doctor must come up with a treatment plan. Here are the basic categories that I know of to boost your testosterone:
i) Go Natural. Almost everyone can boost their testosterone a little through lifestyle changes. There are many ideas for this on my site and they include such things as competition, correcting sleep disorders and depression, weight lifting, certain supplements, getting more sleep and so on. From what I have seen, these will only raise a hypogonadal man's testosterone a little. But these need to be corrected anyway for your general health and so many men will want to try this route first assuming that their low testosterone is not causing major health issues. [FOR MORE INFO: How to Increase Your Testosterone Naturally.]
There is one potential exception: Weight Loss. If you are 50+ pounds overweight - and most American men over the age of 40 are - then you can very likely greatly increase your testosterone levels and drop estradiol as well. It is even possible to double your testosterone levels in some cases: see my link on Testosterone and Weight Loss for more information.
CAUTION: Low testosterone can lead to many nasty health conditions including anemia, osteopenia/osteoporosis, elevated insulin with prediabetes and/or diabetes, etc. If you have one of these conditions, going natural may not be a good option.
ii) HRT (Testosterone Replacement Therapy). There are many options available here: testosterone patches, injections (cypionate, enanthate and undecanoate depending on your country), pellets, compounded creams, brand name topicals (Androgel, Testim, Fortesta, Axiron). Each of these have their advantages and disadvantages. [FOR MORE INFO: Testosterone Therapies.]
NOTE: Very often Armidex (anastrazole) is given along with HRT, because the elevated testosterone will increase estradiol along with it.
iii) HCG Monotherapy. HCG is an "LH (leutening hormone) analogue", meaning it is almost identical in structure and function to LH. Of course, LH is what stimulates the testes to produce testosterone and so, as long as one's testes are functioning correctly, HCG can give a substantial boost in testosterone. [Arimidex is often given with it, because the increase in testosterone will increase estradiol as well.] This option often works in men wishing to maintain fertility. [FOR MORE INFO: HCG Monotherapy.]
iv) Clomid. Clomid is a pharmaceutical in the SERM family that acts on the hypothalamus and stimulates testosterone production in men with a functioning pituitary and testes. Unfortunately, many men experience no increase in libido on Clomid and often have other estrogenic symptoms. (Clomid is composed of two drugs actually, and one of those is estrogenic.) [FOR MORE INFO: Testosterone and Clomid.]
NOTE: It is uncommon, but a few savvy doctors will try to diagnose whether or not you have primary or secondary hypogonadism. However, few urologists, PCPs or endocrinologists will do this simply because their solution for both conditions is HRT.
f) Prolactin. If your testosterone is low, then imo you shoud have your prolactin pulled and the reason is that elevated prolactin is quite common and will lower libido and total testosterone. [FOR MORE INFO: Testosterone and Prolactin.]
g) Estradiol Management. If you and your doctor decide that your estradiol (using the ultrasensitive test) is too high, then one can consider a) losing weight which can dramatically lower estradiol and/or b) low dose Arimidex (anastrazole). Typical dosages for men on HRT are .25 mg - .50 mg twice per week. [FOR MORE INFO: Testosterone and Arimidex; the Testosterone-to-Estradiol Ratio.]