Andropause: What Men Need to Know

Why older men fall short

While testosterone declines naturally over age, “not every older person has low testosterone,” says Dubin. Some of it comes down to how we age. “Obviously as we get older, we maybe lose our ability to be as active. Maybe our diet is more lax, we start gaining weight, we start developing high blood pressure, maybe diabetes,” he says. “As we get older, you’re just having other health issues that can, in combination, result in lower testosterone.”

Trying to tease out causality — is something the cause of lower testosterone or the result of it — can be challenging. But there is plenty of evidence that keeping testosterone levels up has immense beneficial effects, says Morgentaler. “We have double-blind studies where you take people with low bone density and low testosterone and give them testosterone versus placebo,” he says. “The guys on placebo don’t gain bone — as a matter of fact, over time and aging, it decreased. But in the group that got testosterone, it increased.”

So should men rush to their doctor for blood work? Maybe not, says Nannan Thirumavalavan, M.D., chief of male reproductive and sexual health at University Hospitals Urology Institute in Cleveland, and associate professor at Case Western Reserve University. Testosterone is not usually screened in standard blood work, partly because it can be hard to measure: Levels can fluctuate by as much as 70 percent throughout the day, says Thirumavalavan, and can be influenced by everything from your circadian rhythm to how recently you exercised to how well you slept the night before.

“The reality is, if you check everybody, you’ll have a large chunk of people who have no symptoms whatsoever and end up with a low testosterone level just because you happen to check it,” Thirumavalavan explains.

That’s why the American Urological Association guidelines call for at least two tests — and, importantly, the presence of “symptoms and signs” — before issuing a low testosterone diagnosis.

According to Dubin, the symptom most suggestive of low testosterone is a reduced sex drive. “But it can also present as mood changes, difficulty losing weight, breast development, low energy, erectile dysfunction and body hair loss,” he says.

How to keep your T from toppling

Testosterone therapy, in which patients receive a synthetic version of the hormone, is not the only answer, says Morgentaler. Changes in lifestyle can also affect testosterone levels.

• Get regular sleep. “Sleep is critical,” Morgentaler says. Being consistent with your sleep times, and regularly getting enough shut-eye to feel refreshed in the morning, can make a huge difference: Research suggests that night workers suffering from what’s known as “shift work sleep disorder” can also have lower testosterone levels.
• Drop 15 percent. The second most important factor, says Morgentaler, is “to try and stay as trim as you can — a lot of the decline with testosterone is because we gain weight as we get older, generally.” Studies of bariatric weight-loss surgery have seen patients record dramatic increases in testosterone levels after the procedure — although, Morgentaler notes, “you have to lose about 15 percent of your weight to start to get clinically significant increases in your testosterone.”
• Find a stress outlet. A small study of Swiss cadets in officer training school found that during a military field exercise, the stress hormone cortisol worked inversely to testosterone, meaning the more you have of one, the less you have of the other.
• Eat healthier food. The Mediterranean diet emphasizes fruits, vegetables, whole grains, beans, nuts, legumes and fish. But more than 50 percent of calories in the American diet come from ultraprocessed products. One review of studies suggests that both strict dieting and a lack of nutrients can negatively impact testosterone levels. Low-fat, low-calorie diets in particular can reduce a man’s T. The fats found in fish and olive oil have been linked to improved testosterone.
• Stop smoking and drinking. Despite their manly mythos, both habits reduce testosterone levels.
• Know squat. Exercise in general is helpful, but compound muscle exercises like squats and bench presses are particularly effective in raising levels.

The promise, and problems, of testosterone replacement

Unfortunately, most of us like fast fixes, which is why going the TRT route has become so attractive, Thirumavalavan says. Earlier this year, the Food and Drug Administration (FDA) removed a so-called “black box warning” of increased risk of cardiovascular issues and prostate cancer with testosterone therapy. That came on the heels of a large, rigorously controlled study known as TRAVERSE, published in 2023 in The New England Journal of Medicine, that failed to find an association between testosterone therapy and cardiovascular risk, as well as prostate cancer.

But TRT still comes with a number of potential side effects. The most drastic, perhaps, is related to fertility. “Testosterone, if you take it, will shut down your sperm production,” says Thirumavalavan. “It’s a pretty consistent effect, good enough that it’s been tested as male birth control.” While it may seem counterintuitive that bolstering testosterone would lower one’s reproductive fitness, as Thirumavalavan describes it, “your pituitary gland in your brain basically says, ‘Hey, there’s all this testosterone here, so your testicles stop making their own.’” Other potential side effects, perhaps more relevant to older men, are a raised red blood cell count (which carries a risk of blood clotting), high blood pressure, acne, fluid retention and swelling.

These kinds of side effects are the reasons doctors will generally not prescribe TRT to patients simply looking to bolster their testosterone to “supra-therapeutic” levels. “My goal is to treat low testosterone as a disease state, not to optimize normal levels,” says Dubin. “If you come to me with normal levels and want to be on TRT, I do not prescribe it.”

That doesn’t necessarily mean you can’t get testosterone, with or without proper medical screening. In a study published in JAMA Internal Medicine in 2022, Dubin posed as a “secret shopper” and attempted to buy testosterone from a number of direct-to-consumer online platforms. While the platforms theoretically require lab results, his normal level lab results were often enough to procure testosterone — “in some cases,” as the study notes, “guided by nonmedically licensed individuals with unclear oversight while failing to convey the risks and benefits of testosterone therapy.”

Dubin says some men just want to take their health into their own hands. Other men worry about the stigma attached to the symptoms of low testosterone. “A lot of times, it’s embarrassing to admit that we’re not what we used to be,” says Dubin.

If you are interested in supplementation, start by talking with your doctor. There are any number of FDA-approved methods, including pills, patches, nasal sprays, injections, topical gels and subdermal pellets. Thirumavalavan says it all comes down to patient preference (though topical gels are not advised in households with children, given the risk of accidental contact).

One person who swears by testosterone therapy is Dubin’s grandfather Norman, 85, retired and living in Boca Raton, Florida. (While Dubin says he occasionally “looks over his labs,” he is not his grandfather’s doctor.) Once a week, the elder Dubin sticks himself with an insulin needle, injecting half a milliliter of testosterone. He began doing it in his early 60s. “Emotionally, I was a little bit down,” he says. As someone who had always exercised, “I felt I wasn’t building muscle the way I wanted to.” Under the guidance of his doctor, he takes a blood test every four months, and also takes a pill to prevent the buildup of estrogen, a possible TRT side effect. “It’s not a miracle drug,” Norman Dubin stresses. “You’ve got to do the basics; you’ve got to take care of yourself.” For him, that includes almost daily trips to the gym. “I’ve got wrinkles, I’m not going to lie to you,” he says. “But I’ve still got muscle tone.”