Men’s care

From about thirty onward, testosterone declines by roughly one percent a year. That figure hides a lot. Weight gain, poor sleep, alcohol, sleep apnea and a handful of common medications all push it down faster. The average level in young American men has dropped by about a quarter since 1999, and the drop shows up in men of normal weight as well as heavy ones. Whatever the cause, more men are arriving at forty with less to spend.

The early signs are easy to explain away.

• Tired after a full night’s sleep, and flat by mid-afternoon
• Interest in sex thinning out, with fewer and weaker morning erections
• Weight moving to the middle though you lift the same and eat the same
• Recovery after training taking longer, and strength that used to come back not coming back
• Mood turning short, or simply flat, and concentration going with it

The most reliable of these are low desire, fewer morning erections and erectile trouble, which track testosterone more closely than fatigue or mood.

None of this arrives all at once, which is why most men adjust to it. They train harder, drink more coffee, and assume this is what forty-five feels like. Sometimes it is. Often it is a hormone problem wearing the costume of ordinary aging.

The reference range for total testosterone runs from roughly 300 to over 900 ng/dL, and a man who reads 320 is normal on paper. He may also have been at 700 a decade ago, and the range cannot tell you that. It is built from the population, not from you.

There are other ways a single result can mislead. Testosterone peaks in the morning and falls through the day, so an afternoon draw reads low and a morning draw after a bad night reads low too. Total testosterone can look adequate while the free, usable fraction is not, because the protein that binds it rises with age. A number inside the range settles less than most men are told it does. The diagnosis is made from the level, the free level, and the symptoms together, and if they do not agree, we test again before we do anything else.

About one in four men over thirty has low testosterone, and among men over forty-five who see a doctor it is closer to four in ten. Roughly one in eight of those with symptoms is treated. Part of the gap is that the symptoms get filed under other things, and part of it is fear that has outlived its evidence.

In 2015 the FDA added a heart attack and stroke warning to every testosterone product, based on two observational studies that did not hold up. The TRAVERSE trial then followed 5,246 men at elevated cardiovascular risk for nearly three years and found no more heart attacks or strokes on testosterone than on placebo. The FDA removed the warning in February 2025. The older fear that testosterone feeds prostate cancer has not held up either, and modern trials show no increase. We still check PSA in every man over forty, because it is a cheap safeguard.

We treat men, mostly between 35 and 60, whose energy, sleep, mood, weight or sex drive have changed, and who want the cause addressed rather than the symptoms managed. That includes men who have been told their labs are fine, men who suspect the problem is hormonal and want it tested properly, and men who want treatment without giving up the option of children.

We do not treat everyone. Any of the following rules out testosterone until it is dealt with, and we will say so on the first call.

• Active prostate or breast cancer
• A heart attack or stroke in the last six months
• An already high red cell count
• Severe untreated sleep apnea

If the panel points somewhere else, to thyroid or iron or sleep, we will say that too.

I am board-certified in psychiatry and obesity medicine, with fellowship training in anti-aging and functional medicine. My practice began with patients coming to me for depression, anxiety and exhaustion. Past forty, a striking number of them got better when we treated their hormones directly. Men in particular tend to arrive with a diagnosis of depression or a lecture about discipline, and that experience is why mood, energy and weight are treated here as symptoms to explain rather than verdicts to accept.

This is a physician-led clinic that specializes in fixing your hormones. Medications are passed on at cost and we do not make money on them, so there is no incentive to prescribe more than you need. You see the same physician every visit, you can message your physician directly between visits, and you are seen within days, from home.

We also dose differently from most clinics. The traditional approach is a large injection every two weeks, which produces a peak in the first few days and a trough by the end, so you feel good one week and flat the next. Our default is a small dose two or three times a week, which holds levels steady and cuts the main side effect, a rising red cell count, from about two thirds of men to about one in eight. We do not use pellets, which spike and then fade over a few months, cannot be adjusted once they are in, and occasionally work their way back out.

Everything begins with a fasting morning panel, drawn before ten. Total and free testosterone, SHBG, LH and FSH, estradiol, a blood count, PSA for men over forty, thyroid, blood sugar, lipids and a metabolic panel. We want the whole picture, because a low result with a high LH means something different from a low result with a low one, and because thyroid and sleep problems often sit alongside hormonal ones.

For most men the protocol is testosterone cypionate, 40 to 70 mg under the skin two or three times a week, adjusted to your labs. A daily cream works for men who would rather not inject. Testosterone shuts down sperm production while you take it, so fertility is planned from the start. Men who may want children add hCG to keep the testes working, and men actively planning a family often start with enclomiphene, a daily tablet that raises your own testosterone instead.

• Week 0. A free fifteen-minute call, then the baseline panel.
• Week 2. Your results are reviewed with you and a protocol is agreed.
• Weeks 6 to 8. Labs rechecked and doses adjusted. This is where most of the real work happens, since almost nobody’s first protocol is their final one.
• Month 3. Most men are at a steady state, with reviews twice a year from there.

Sex drive, mood and energy are usually the first to move. Body composition follows over three to six months, with trials showing around 3.6 kg of lean mass gained and 1.8 kg of fat lost, and the men who train see considerably more.

Erections improve for most men but not all. Where they do not, the cause is usually vascular as well as hormonal, and we will tell you if it is.

Side effects are mostly predictable and mostly manageable. Red cell count is the one we watch closest, and treatment is paused if it rises too far. Blood pressure goes up a few points on most formulations. Some men get acne, some retain a little fluid, and some notice the testes shrink, which the hCG prevents. Testosterone does not make a man aggressive at physiological doses. What men more often report is the opposite, a short fuse becoming a longer one.

Monitoring is deliberately simple. Labs at six to eight weeks, at six months, and every six to twelve months after that, with PSA for men over forty. The six-month review is where we decide together whether it is working well enough to continue. There is no age at which therapy must stop. It continues as long as it is helping and the balance stays in your favour, which for most men is years.

Treatment works better alongside the ordinary things. Losing ten percent of your body weight raises testosterone by roughly 80 ng/dL on its own, treating sleep apnea raises it further, and weight training two or three times a week is where most of the muscle and fat change actually comes from. We will say so, and we will not try to sell you anything for it.

The cost is simple too. The first call is free. Starting covers the baseline panel, your consultation, your protocol and your first month. After that, membership includes all labs, all consultations and direct messaging, with medications at cost.

• Low testosteroneWhat low testosterone feels like, how it is diagnosed, and the protocol we use for men and women.
• How it worksWhat happens, in order, and what each part costs.