Natural Versus Testosterone Therapy

NATURAL VERSUS TESTOSTERONE THERAPY

This book is about all the things that I wish someone had told me before I started testosterone therapy.

I have been on testosterone therapy for many years now and it has been a very positive, life changing experience for me overall, especially the last few years on my latest protocol.  Of course, I am not alone and have run across many other men that have also had a great experience since I created PeakTestosterone.com back in 2007.  However, I can tell you that I see on the Peak Testosterone Forum these two diametrically opposed viewpoints in about equal numbers:

Position 1:  Bioidentical testosterone is a natural molecule that a man’s body craves and needs.  Testosterone replacement therapy is a godsend when done correctly in a truly low testosterone man and is usually the most powerful and life changing solution.  Low dose HCG can be added to protect testicular function if desired.

Position 2:  Testosterone replacement therapy is unnatural and forces a significant shutdown of the hypothalamus and pituitary.  Fertility, cortisol, DHEA and/or thyroid hormones may be negatively impacted in the long term.  A man should do all he can to try to solve his low testosterone naturally and then only consider Clomid or HCG Monotherapy as therapeutic solutions (unless he is primary hypogonadal). 

Who is right?  I do not believe there is a one-size-fits-all solution when it comes to testosterone therapy, and I do my best never to push men into standard testosterone replacement therapy (TRT) even though I personally have had an excellent experience to date.  My goal is instead to give them a solid background in ALL the alternatives out there to boost testosterone, including trying to raise it naturally.  It is also important that men are aware of the potential risks involved – and less well known benefits as well - in treating/not treating low testosterone. So why, some of you may be asking yourself, Do we need a book on testosterone when we could just ask our doctor any questions that we have?  Well, if you read this book, you will see that anything to do with hormones, while not rocket science, is quite involved.  For your doctor to answer your questions about low testosterone, he or she would have to spend at least two hours with you.  If you don’t believe me, just scan through the material in this book, and you will see why the vast majority of physicians will never take the time necessary to give you the knowledge you need to make an informed decision.

I once asked my current Primary Care Physician some questions about testosterone therapy, and he basically told me that the statistics showed that he had 15 minutes to spend with me or he would lose money.  I guess I can’t fault him for being honest, because he has large real estate, staff and equipment payments each month.  But that still didn’t help answer my questions.  And going to a urologist or endocrinologist is little better usually:  most doctors simply do not want to spend time on hormones, because the margin is simply too low for them to make a profit.

The bottom line is that men with low testosterone (low T), are often left with the daunting task of trying to rapidly educate themselves and make a quick decision.  Usually, low T men feel lousy and are struggling in their relationships and/or career, so the pressure is on.  They also tend to be overwhelmed by so much information out there on this topic.  Of course, it is my hope that this book will fill in a lot of those critical knowledge gaps for you to be able to negotiate well with your doctor about the best options for you.

That kind of philosophy is basically why I started my site, PeakTestosterone.com.  My hope was that I could spare many men out there the many years of needless suffering that I went through.  It was over 10 years from the initial onset of my symptoms before I was put on any kind of testosterone therapy, a rather pathetic protocol that only made marginal improvements.  It took still another 5+  years after that before I was placed on my current life-changing testosterone cypionate injections.  My point is that it takes a lot of time to work one’s way through the system unless you have the basic information that you need.  My goal is to shorten the time that you need to get your hormones optimized and save you the guess work that I see many men suffer through.

With that in mind, I have taken what I consider to be the best and most critical pages about testosterone on my site and placed them into this book.  My site is much, much more than just testosterone by the way, and I hope you’ll check it out.  I have what I consider to be excellent information there on other hormones, nitric oxide, erectile strength, prediabetes, prostate cancer and an abundance of other men’s health topics.  So please check it out when you get a chance and say hello when you visit us on the Peak Testosterone Forum.  I am on there regularly and enjoy chatting and answering any questions that I can.

Let’s get started with what I call my Testosterone Step Plan.  This is basically a logical, methodical program to guide you through most of the core issues that a man needs to deal with when it comes to low testosterone.  I want to be clear that I am not trying to funnel anyone into a certain treatment protocol – that’s between you and your doctor.  My purpose is simply to expose you to enough foundational material that you can talk shop with your physicians and get the kind of protocol that best fits your situation.

Measure Your Total Testosterone

STEP 1.  Pull Your Total Testosterone.  The first step in evaluating your testosterone status should start with pulling your total testosterone.  In my opinion, every man should pull this number periodically, symptoms or not, in order to have a good baseline.  As you'll see below, it's about $25 now here in the U.S.  It is fast, cheap and very important to your health. (We will talk about free testosterone shortly.)

One of the things that I have discovered as I have begun to research and monitor my own health is that my physicians - God love 'em - do not always test everything they should test nor monitor as frequently as is necessary. This is nothing against them, of course, as they have limited time and are under obligation to insurance companies and fellow physicians to minimize costs as much as reasonably possible. I know that in my own life I was low testosterone for years before I convinced my physician to finally pull my T.  And it was years after that that anyone pulled my prolactin, estradiol and TSH. These all should have been looked at, but it simply never happened. And I could have probably avoided a great deal of heartache and suffering if I had simply had done these tests myself and shown them the results.

I am NOT suggesting that you become your own doctor, but in the U.S. and some other countries, there is considerable medical freedom and one has the right to monitor one's health.  Think of this: your body and mind are an incredibly complex and highly tuned machine. It makes a combustion engine look like a play toy. Does your doctor really have the time to see if you need a tune up? 99% of the time your doctor is too busy just trying to keep patients alive and semi-functional!

Consider my situation:

—I have never had a homocysteine tested by any doctor. 

—I have had ferritin tested only once. 

—I have never had any thyroid hormones examined except TSH and total T4. 

—I have had C-Reactive Protein (CRP) tested maybe twice. 

—No doctor ever looked at my LH, FSH or prolactin in my hypogonadal days.

Is my situation unusual?  Certainly not.  There just aren’t the financial and time resources available for decent testing in the great majority of insurance-backed systems.  The bottom line is that you are probably going to have to do some self-testing, or perhaps find a integrative doctor or naturopath on a cash basis that can help you do the same.

For all of these reasons I have compiled a list of testosterone labs that pull various hormones for men based on Peak Testosterone Forum posts that I have received over the years. I have also included some commentary about what some of these specialize in and what they can/cannot be used for.  Almost all of these labs are U.S. only, but there are a couple of overseas exceptions as you will see:

CAUTION: I do not have any personal knowledge or affiliation with any of these labs. You must do your own research, i.e. caveat emptor.

1. DiscountedLabs.com.  This is Nelson Vergel's new lab, and it uses LabCorp on the back end from what I understand. Nelson has been doing testosterone replacement therapy (TRT) just about forever and has become one of the foremost lay experts. You will hear his name pop up from time to time as you study TRT and men's health issues. He sent me an email where he promised to beat anyone else's prices. And it sure seems to be the case!  I have used Discounted Labs and had a good experience.

2 Health Tests Direct.  Until Nelson came along, this lab had some of the best prices around: they literally dropped the floor out of the market on some of the basic tests that men do quite often. I have used them a number of times, and they are also known for offering both Sonora and LabCorp options for many of the tests.  I have used them and had a good experience.

3.  Life Extension Foundation.  One of the older and more respected supplement companies, LEF is known for its in depth articles and good support staff.  One very interesting thing that you can get, through them, is a wide variety of lab panels at LabCorp.  They have for example an Inflammation Panel and a Cardiac Panel that I have wanted to get myself that includes many of the key heart disease risk factors such as Chemistry Profile (Complete metabolic panel with lipids) Complete Blood Count (CBC), C-Reactive Protein (high sensitivity), Fibrinogen, Homocysteine Vitamin D 25-OH.  They also have some more specific blood draws for things like CoQ10 and cortisol. The prices are quite reasonable and, of course, it's nice to deal with a well-established company.

One of the panels many men would be interested in is the Male Panel, which includes the Chemistry panel (complete metabolic panel with lipids), CBC, DHEA-S, DHT, Estradiol, PSA, Pregnenolone, Total and Free Testosterone, Sex Hormone Binding Globulin (SHBG), TSH, Free T3.  So in one shot you've got a lot of questions answered dealing with male hormones, especially the ones that can directly impact your sexual health.  The cost as of this writing was about $224 for members and $399 for non and membership where a one year membership cost $75. 

I have purchased a number of labs through LEF with good success and been quite impressed with their support staff who will answer questions. 

NOTE: You'll want to check out that the above test uses the correct estradiol test for males. If you happen to be low estradiol, then the standard test will often not give you correct results based on what I have seen – more on that subject later in the book.  Talk to the lab and make sure you are getting the correct test.  See the end of this book and the section on estradiol for more information.

4.  ZRT Labs. This is another reasonably priced lab.  They offer both saliva and blood spot testing. One of our senior posters on PeakTestosterone.com used them several times to examine some standard male hormones as well as adrenal and thyroid function. One intriguing panel is called the Female/Male Saliva Profile I and includes the following: five (5) tests: Estradiol (E2), Progesterone (Pg), Testosterone (T), DHEA-S, and morning Cortisol (C1) for $170 as of this writing. [1] Blood spot testing tends to be a little more but is still (relatively) inexpensive.  Also, I have recently seen some ZRT tests on Amazon.  (Keep in mind that the only hormones test that you should get via saliva testing is cortisol.)

5. SaveOnLabs.  This lab was brought up on the Peak Testosterone Forum as another company that has arrangements with LabCorp at a discounted price for a wide variety of hormone panels. [5] One of our regular forum posters mentioned them and they also have been mentioned by several well-known online physicians. [3] Their panels are a little more expensive that those of the saliva testing labs but still quite reasonable. For example, they have a Male Hormone Panel that includes Estradiol, Sex Hormone Binding Globulin (Serum), Dehydroepiandroster Sulfate (DHEA), Testosterone (Free, Direct) for $260 as of this writing. [4]

NOTE:  One thing I love about LabCorp is that they have moved their hypogonadal threshold up to about 350 ng/dl, a little above the ridiculously low values seen on virtually all other labs that lie between 260 and 280 ng/dl generally.

6. Canary Club.  The same poster mentioned in #3 above wrote that if you can afford $255 bucks, join canaryclub.org (its free) and use their discount to order the HIS saliva/blood spot panel from ZRT labs. I did this and between the questionnaire and 7 page response from them on my test results it helped me get a sense of where I was at. [2] Of course, a 7 page report accompanying lab results is impressive and reveals the fact that Canary Club has very thorough commentary and analysis on your hormone results.

7. (U.K. Testing) Private Blood Tests.  U.K. guys, from what I have seen on the Peak Testosterone Forum, have a notoriously difficult time getting treatment and testing.   One of our posters wrote that he had found a useful website here in the U.K., www.privatebloodtests.co.uk , this allows you to run bloods at a local hospital without going through your GP, which is useful for tracking things like Clomid. [5] Again, I do not know anything about them, other than what was mentioned in this post, so do your own research.

8.  (U.K. Testing) Blood Tests London.  One of our posters also recommended bloodtestslondon.com.  His comments were that the prices were very competitive and they turned my thyroid blood work around in less than 1 working day. If any of the blood results are out of range then they get a doctor to comment on them (included in the price). Again, I do not know anything about them, so do your own research.

9.  PrivateMDLabs.  This lab, according to one of our veteran posters, uses blood draws throught LabCorp.  This one has been used by a couple of men and the only negative comment was that they have a male panel that is not as comprehensive as I'd like, but includes some things that are worth monitoring. [7] 

10.  Rhein Labs.  This lab specializes in testosterone and estrogen-related metabolites and can really help you diagnose the root cause of your hormonal issues.  Check out this thread for sample results and costs from one of the senior posters on the Peak Testosterone Forum. 

11.  Direct Labs.  I have used this lab for hair testing.  However, they have many other tests available as well. 

Determine if You Are Hypogonadal

STEP 2A.  Determine if you are hypogonadal: 

The second step in evaluating your testosterone is to match yourself up with the medical definition of hypogonadism, a term that simply means clinically having a low testosterone blood level.  A big percentage of physicians out there, especially (and ironically) endocrinologists, believe that hypogonadal testosterone levels are in the 250 to 280 ng/dl range.  As I will show below, there is an abundance of research that shows this threshold should be raised into the 350-400 ng/dl range and perhaps even higher.  In addition, other related parameters, such as symptoms and free testosterone levels, should also be considered.  (See my chapter on free testosterone levels for more information, because quite often a man will have low free and bioavailable testosterone and low medium total testosterone due to high SHBG.)

On this page I want to show just a fraction of the research that shows that the hypogonadal threshold should not be set as low as it is. For example, I will show below how many low testosterone symptoms can be corrected by raising testosterone levels according to the studies.

CAUTION:  Before going on, I want to point out that testosterone therapy is certainly not a silver bullet that works on all men in all cases. Many men go on TRT (Testosterone Replacement Therapy) and notice little difference. In some cases this is because the doctor did not significantly raise testosterone levels or used a poor protocol. Yet in still other cases, classic low testosterone symptoms have other root causes that need to be addressed, such as hypothyroidism, low cortisol or significant atherosclerosis, all of which are quite common.  Most importantly, and as you'll see in other steps, being hypogonadal does NOT mean you should just jump into TRT. 

What Is the T Blood Level Used for a Diagnosis of Hypogonadism?

It always struck me as very arbitrary how testosterone deficiency was defined by most practicing physicians.  For years most physicians decided to treat or not to treat based on the bottom value of their lab's total testosterone range.  So, for example, consider what this man posted: [1]

"I got ahold of the lab results from my first testosterone test.

Total Testosterone 194———reference range———-> 241-827ng/dL"

Now this man will have no trouble getting treatment simply because his total testosterone reading of 194 is well below the bottom range value of 241.  Basically, the physician trusts the labs definition of what low testosteorne is and treats accordingly.  However, if the man had a value of 242, many physicians would not treat him, which is unfair in my opinion as some of the labs are using incredibly low levels for hypogonadism.  

The labs and physicians are simply not using common sense in my opinion.  Why do I say that?  Testosterone in the 200's is below that of the average 80 year old man!  Stop and think about it.  Why would we define clinically low testosterone based on the levels of sickly seniors of a very advanced age?!   You can check the numbers out for yourself in my page on Average Male Testosterone Levels by Age.

Evidence as to just how old school this is can be shown by the fact that there is one forward thinking lab, LabCorp, that has raised their reference ranges anyway.  And LabCorp is the biggest lab in the nation, so, hopefully, others will follow some day.  Look at what this poster on the Peak Testosterone Forum wrote:

"I am seeing far less hair on my pillows and noticeably less in my hands after washing my hair. Metabolism seems to have picked up some as well.

Testosterone serum 343 L Labcorp range=gold standard (348-1197 ng/dl)

Labcorp changed their entry level range for what is regarded as hypogonadal serum T levels from 240 ng/dl to 348 ng/dl in October 2011. This has helped many men get a more serious consideration from their otherwise unsympathetic GP's. This new standard has been long overdue for many many years, but finally something has been done about it and Labcorp should be commended. Had this change been made 7 months earlier to when I first had a lab taken at 294 ng/dl in March 2011 my experience regarding testosterone deficiency and the effect it has had on my quality of life may have been very different from what it has been for the past two years."

I think that one can make a good case that 348 is even a bit low, but at least it is a starting point.  And, on a practical level, I can tell you that almost all men writing into the Forum with classic low testosterone symptoms are below this level.  We do get quite a few young guys with levels even higher than this struggling however.

Hypogonadism Between 350 and 450 ng/dl in the Literature:

Again, it is important to note that there is no guarantee that raising testosterone will correct the underlying issues.  However, the point is that it may and, furthermore, many studies show that correcting hypogonadism in the 350-450 ng/dl range will often help alleviate symptoms.  And this begs the question:  if you can fix a man's symptoms at 350 ng/dl, then why isn't 350 ng/dl the threshold for hypogonadism? 

Unfortunately, many doctors are not aware of this.  They still believe that testosterone is just something you give to the patient to make him feel better about himself but really does very little.  Hopefully, the studies below will shatter that myth, and I encourage you to show some of them (in a polite way) to him or her:

1) Arterial Stiffness.  Low testosterone greatly increases cardiovascular risk, which can, of course, manifest in many different forms. High blood pressure, low vasoreactivity (arterial responsiveness), arteriosclerosis (arterial plaque) and endothelial dysfunction are some of the primary culprits. As we’ll show below, low testosterone is associated with almost all of these.

Another very dangerous cardiovascular risk factor is arterial stiffness, or hardening of the arteries, and low testosterone has been shown in several studies to be correlated with this condition. [17][18] For example, one study of dialysis patients found that men with total testosterone below 235 ng/dl (8 nmol/l) had increased arterial stiffness. Although this study was on a unique subset of the population, it was controlled for a number of important cardiovascular risk factors including BMI (a measure of body fat) and C-Reactive protein (a measure of systemic inflammation). Another example comes from prostate cancer patients, who are often pharmaceutically driven into a hypogonadal treatment state. These men, who are already undergoing cancer treatment, also experience increased arterial stiffness due to the anti-testosterone therapies.

Why is hardening of the arteries so dangerous? The root causes of arterial stiffness are generally loss of flexible connective tissues, decreased vascular muscle tone and plaque buildup. Of course, the latter is famous for also narrowing arteries and raising the potential for higher blood pressure, blockages and stroke. And low testosterone definitely accelerates plaque buildup in the arteries.

Hardened arteries are also dangerous, because they can result in some unexpected phenomenon, such as creating a greater blood pressure spike that can do damage over time. Even worse, stiffened tissues are less able to absorb this pressure spike and thus allow more injury to surrounding tissues, especially in the brain and kidneys.

Does supplemental testosterone help improve arterial stiffness in men with low T? One study tried to answer this question by examining two groups of men, a hypogonadal group with average arterial stiffness of 8.9 and a control group with a lower reading of 6.78. Within 48 hours of testosterone therapy, the low T men were improved to an average arterial stiffness of 8.24 (measured as PWV).[21] The units actually are not important: the point is that testosterone therapy overcame in two days about a third of the arterial stiffness on average that these men had accumulated from years of basement level hormones.

2) Depression.  Most men will will not talk about it, but depression is a huge and common issue with men.  I see it all the time on the Peak Testosterone Forum. And many guys with low testosterone have experienced firsthand the fact that testosterone profoundly affects the brain. Several studies have verified this and shown that low testosterone can lead to mood issues and depression. The threshold at which this becomes statistically significant appears to be around 350 ng/dl (10.2 nmol/l). [22] Researchers have also found that testosterone does not just affect how you feel but also how you think. One study observed that low testosterone men experienced memory issues in a manner very similar to that experienced by Alzheimer and dementia patients. [23]

Free testosterone levels may play even more of a role in this case. One group of scientists rediscovered the 300 ng/dl (10.2 nmol/l) threshold for depression but found that the free testosterone level was 10 ng/dl. This is a little above what is normally considered hypogonadal, about 5 ng/dl, in some of the studies. The odds of depression were found to be between 1.5 and 3.0 times more for the lower quintile guys, depending on whether one used total or free testosterone numbers. The bottom line is that if either free or total testosterone is low enough, get ready for a bumpy emotional and mental ride. [24]

NOTE: It is extremely critical to get depression under control. Not only does it tend to lower testosterone, it is also a physical stressor than can literally destroy neurons and raise your risk of cardiovascular disease due to elevated cortisol levels.

As anticipated, testosterone therapy benefits men with low testosterone and depression. One study looked at depressed men with testosterone below 350 ng/dl (11.9 ng/dl) and found that when these men were given testosterone therapy (gel), there was substantial improvement. [25] Of even more weight is the fact that a recent meta-analysis examined seven different studies and found that not only did testosterone therapy improve depression in hypogonadal men, but in men with a broad range of testosterone levels. [26] One can’t help but wonder how many men out there are struggling with depression that do not realize that low testosterone is playing a role.

In addition, testosterone has been found in several studies to be related to mood. [29][30] Mood may seem a somewhat subjective word, but, as expected, researchers have studied the subject in considerable psychological detail. For example, one study found that testosterone replacement improved energy, well/good feelings, and friendliness and decreased negative mood parameters including anger, nervousness, and irritability. [27] Furthermore, when studying the use of Androgel, scientists found that mood parameters improved rapidly and were maintained throughout T treatment. [18]

3. Metabolic Syndrome.  Prediabetes, when one begins to lose insulin sensitivity, is an absolute epidemic in the U.S. and other modern cultures right now.  The current prevalence is about a fourth of the population. Common symptoms, such as visceral (belly) fat, low HDL, high triglycerides and blood pressure, often accompany it in a suite of symptoms called Metabolic Syndrome (Met-S).  My guess is that around a half of the guys that show up to my site over the age of 40 probably have Met-S.  Researchers have found that Met-S has been tied to an increased risk of developing cardiovascular death and all-cause mortality. [64][65] It also increases the risk of erectile dysfunction, since it ages the arteries and accelerates plaque build up.

What does Metabolic Syndrome have to do with low testosterone? As discussed, low testosterone raises insulin levels very significantly and thus directly worsens or initiates Metabolic Syndrome. For example, one study of middle-aged men found that those in the lowest fourth of total testosterone were 1.9-2.5X more likely to develop Metabolic Syndrome over the next 11 years.  The threshold for the quartile of total testosterone was 450 ng/dl (15.6 nmol/l). [66] 450 ng/dl would be considered reasonable testosterone by most doctors and yet this study indicates that many men may be getting into trouble near this threshold.

4) Muscle and Fat.  A number of studies have shown that testosterone will add muscle and decrease fat.  For example, one study on senior men (over age 65) found that fat mass decreased and lean mass increased in the testosterone treated men. [4] This is truly remarkable considering that the men were put on no special diet or exercise program:  their body composition just magically improved for the better with the additional testosterone.  It should be noted that these were not large improvements in body composition:  it will always boil down to diet and exercise in the end, but testosterone can clearly be a help.

5) Memory.  Doubling - actually a little more than doubling - senior males' testosterone levels led to significant improvements in visual and spatial memory.  I can tell you on a practical level that I very often get comments from men on testosterone therapy of the incredible effect that testosterone has on the brain.  In fact, some executives now are going on testosterone just to improve their careers!  I'm not advising that, of course, but the phenomenon is interesting and you can read about it in this Forum Post.

6) Diabetes. Great improvements in type II (adult onset) diabetes can often be achieved with testosterone therapy in middle-aged and senior men via TRT.  Again, I relate the story of one TRT clinic who told me that ALL of their diabetic patients had completely eliminated their need for insulin after testosterone therapy.  A couple of men still had to take Metformin, but, nevertheless, this is a dramatic improvement.  Of course, the reason is that increased testosterone led to decreased insulin levels and improved insulin sensitivity in general.  Nice!

7) Erectile Dysfunction and Libido.  Many studies have shown the positive effect of additional testosterone for men with low T in the area of sexual health.  For example, one study on hypogonadal men found that morning erections, total erections and libido were all improved after increased T levels. [6] The authors wrote: all had a rapid and dramatic recovery from major depression following testosterone augmentation. Wow!  How many psychological disorders have a 100% success rate?!?

CAUTION:  Do not stop any medications or treatments without first talking to your doctor.

8) Venous Leakage.  This is an ugly condition that afflicts men, young and old.  It very often has a root cause of low testosterone levels.  The reason is simple:  low testosterone leads to a decay of the internal structures of the penis.  This decay does not allow the veins to be closed off during an erection and thus the outflow from the penis is as great as the inflow and erections are either quickly lost or, in the worst case, impossible to even achieve. For more information, see my link on Venous Leakage.  And several studies have shown the benefit of testosterone levels to men with venous leakage.  One study showed that well over half of men were either partially or fully cured of their venous leakage from testosterone therapy. [8]

This list could be greatly extended.  The point is that eliminating a testosterone deficiency and restoring more youthful levels can significantly or even completely reverse many key symptoms. Should this not be the definition of a true deficiency?  And is this something to discuss with your physician?

Consider Free Testosterone Levels

STEP 2B. Consider your free testosterone levels if needed:

There are two reasons that I know of to pull your free testosterone:

a) If you have medium or low medium total testosterone, it is possible to have proportionately lower free testosterone if you have high SHBG.  The low free testosterone, from what I have seen produces, just as many symptoms as low total testosterone, and this is because it is the free testosterone that really acts on the tissues anyway.  (Actually, it is bioavailable testosterone but one thing at a time.)

b) Many studies use both total and free testosterone as independent markers of hypogonadism.

Also, another reason to understand free testosterone levels deals with a question that I get quite often on the Peak Testosterone Forum:

My doctor says my free testosterone levels are fine, but I still feel lousy.  Are my levels really okay?

That's a tough question to answer and the reason is simply that there is such a wide variety of answers out there.  I'm going to cover some of the free testosterone hypogonadal ranges that I have seen in the research, and you'll see that this is not easy to get your arms around.  And it is, by the way, one of the reasons that I use total testosterone in my discussions with men about the subject.  Doctors, labs and researchers seem very divided on free testosterone, which is not nearly as much the case as with total.  For example, the unspoken rule of thumb that I now see out there with urologists and PCPs is that, while upper 200's (in ng/dl) for total testosterone is considered hypogonadal, a man can get TRT if he is the 300's.  So the variation between hypogonadal and treatable is maybe 30%.

Again, this is not the case with free T and let me give you some examples below.  I do want to say one thing about the units involved first.  All my numbers below are in ng/dl and often free testosterone is given in pg/ml.  The conversion is simple:  you simply take the free T number in ng/dl and multiply it by 10 to get the equivalent in pg/ml.

1.  1.5 ng/dl (Journal of Urology).  This is the lowest threshold that I have ever seen for defining hypogonadism:

Low levels of TT and FT were defined as less than 300 and 1.5 ng/dl, respectively. Markedly low levels of TT were defined as less than 200 ng/dl. [2]

We'll go into this a bit later, but 1.5 ng/dl is VERY low free testosterone.

2. 3.5 ng/dl (Quest Diagnostics).  One of the biggest labs in the United States is Quest and they list, for their top tier LCMSMS test a range of 35-155 pg/ml for an adult male aged 18 to 69. [3] As mentioned above, this translates to 3.5 ng/dl.

3. 4.0 ng/dl (LabCorp).  The biggest lab in the U.S. is LabCorp and they weigh in with a hypogonadal free testosterone threshold of 4.0 for an adult male. [4]

4. 6.5 ng/dl (Cleveland Clinic Journal).  This journal weighs