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A Vicious Cycle Undermining Men’s Health

Posted on by Akash Kapadia, MD in ,

Man sitting on park bench with legs crossed, smiling

Obesity, left unchecked, has the potential to outpace smoking as the leading preventable cause of death in the United States.¹ Obesity raises LDL (“bad”) cholesterol and triglycerides, lowers HDL (“good”) cholesterol, and interferes with how the body responds to insulin. Over time, this imbalance drives up blood sugar and inflammation, setting the stage for heart disease, stroke, diabetes, and other chronic illnesses.

But beyond the cardiovascular and metabolic impacts, excess weight can undermine one of men’s most defining hormones: testosterone. Obesity and low testosterone form a self-perpetuating loop that affects everything from energy and metabolism to fertility and confidence. The heavier a man becomes, the lower his testosterone tends to fall – and as testosterone drops, body fat accumulates even faster.

The better we understand this cycle, the more strategically we can intervene to restore hormone balance and improve men’s health.

Understanding Testosterone

Most of us think of testosterone as the ‘male hormone’ because it’s responsible for many of the traits that define male physiology: muscle mass, bone strength, body hair, and the deep voice that emerges at puberty. But it’s also a primary player in reproductive function, sperm production, libido, mood regulation, and even energy levels and metabolism. Simply put, it affects nearly every aspect of men’s physical and mental well-being.

Testosterone levels naturally rise during puberty, peak in early adulthood, and then remain relatively stable for years before gradually declining after 45. Most men retain adequate levels well into older age, but certain factors can accelerate this decline. Among the most significant is obesity. While aging contributes to a slow, predictable drop in testosterone, excess body fat, especially in the midsection, can push levels far lower, and much faster, than time alone. Studies show that waist circumference is an even stronger predictor of low testosterone than body mass index (BMI) – a four-inch increase in waist size can raise a man’s odds of having low testosterone by 75%.¹

One of the mechanisms by which obesity disrupts hormone balance is through aromatase activity. Fat tissue contains an enzyme called aromatase, which converts testosterone into estrogen. The more adipose tissue a man has, the more testosterone gets converted, tipping the hormonal scales and reducing the levels of this vital male hormone.²

Obesity also lowers levels of sex hormone-binding globulin (SHBG), the protein that carries testosterone through the bloodstream. With less SHBG, the amount of free, biologically active testosterone drops, even if total testosterone levels appear only modestly reduced.²

Obesity is also closely linked with hyperleptinemia, a state of elevated leptin levels. Leptin normally helps regulate appetite and energy balance, but chronic excess can cause leptin resistance. This resistance can suppress the hypothalamic-pituitary-gonadal (HPG) axis (the brain-to-testes signaling pathway that controls testosterone production) by inhibiting gonadotropin-releasing hormone (GnRH) and luteinizing hormone (LH) secretion. In other words, the brain’s commands to produce testosterone are dulled.²

Insulin resistance and chronic low-grade inflammation, both common in obesity, further impair the HPG axis and directly affect Leydig cells in the testes, which are responsible for testosterone production. The result is a functional, yet potentially reversible, hypogonadism called pseudo-hypogonadism: the testes are still capable of producing testosterone, but systemic factors prevent them from doing so effectively. Removing those factors helps with regaining functionality. Sustained weight loss, whether through diet, exercise, or medical interventions, can restore testosterone levels and help break this self-perpetuating cycle.²

Understanding Bidirectionality

Low levels of testosterone also turn the tables on adipose storage, creating a vicious cycle. Just as excess fat can lower testosterone, low testosterone levels can accelerate fat accumulation, particularly in the abdominal region, while reducing lean muscle mass. This combination worsens metabolic dysfunction, insulin resistance, and glucose intolerance, making weight management even more challenging.

Research also shows that low testosterone can impair mitochondrial function in muscle, reduce insulin sensitivity, and increase visceral fat storage, exacerbating the feedback loop that accelerates metabolic decline. Men with both obesity and low testosterone often show worsened glucose tolerance, higher waist-to-hip ratios, and more pronounced dyslipidemia than those with obesity alone.³

An offshoot of this interplay between obesity and testosterone is erectile dysfunction (ED), which is in itself affected by either on its own and compounded by their simultaneous presence; ED can be one of the first visible signs that something is off hormonally or metabolically.

Low testosterone is rarely the sole cause of erectile dysfunction (ED), but testosterone still has a huge impact on sexual desire, libido, and overall sexual function. While normal adult testosterone levels are not strictly required for erections, hypogonadism (the most common endocrine disorder linked to ED) can reduce sexual interest and responsiveness. ⁴

Obesity itself increases the risk of ED through several mechanisms. Excess abdominal fat contributes to vascular dysfunction, insulin resistance, and inflammation, all of which impair blood flow to the penis. Studies show that men with larger waist circumferences or higher BMI have significantly higher odds of developing ED, independent of age. ⁵

When low testosterone and obesity coexist, their effects on erectile function multiply. Reduced testosterone can dampen libido and sexual confidence, while obesity impairs the physiological ability to achieve and maintain an erection. Even moderate weight loss has been shown to reverse ED in many men, highlighting the interconnectedness of metabolic health, testosterone, and sexual function. ⁶

The bidirectionality of testosterone and increased body mass explains why traditional weight loss efforts alone may only partially restore testosterone levels, and why interventions that address both hormones and metabolism together (such as lifestyle modification combined with medical therapies) can be more effective in the long run. ⁶ Targeted strategies based on individualized health characteristics are the most effective way to truly break the cycle and restore men’s health.

Breaking the Cycle

Lifestyle modification is at the root of almost any ailment, whether or not medical intervention is involved. Restoration of hormone balance is no exception, as diet, exercise, and sustained weight loss can improve testosterone levels, reduce visceral fat, and even reverse erectile dysfunction in many men.

For men with confirmed hypogonadism, testosterone therapy (TTh) can amplify the benefits of lifestyle interventions:

  • Fat Reduction and Muscle Preservation: TTh reduces visceral fat and total body fat while preserving lean muscle mass, something diet and exercise alone often struggle to achieve. ⁷
  • Metabolic and Hormonal Effects: By increasing bioavailable testosterone, TTh can help mitigate some of the systemic suppression of the HPG axis commonly observed in obesity.
  • Motivation and Energy Rebound: TTh can improve energy, mood, and motivation, making it easier for men to adhere to diet and exercise programs. ⁸

Research consistently shows that pairing TTh with lifestyle modification produces the best results. For example, a 56-week randomized controlled trial in men with obesity and low testosterone found that those receiving TTh plus a very-low-calorie diet lost significantly more visceral fat, preserved lean muscle, and maintained weight loss better than those only refining their diets. ⁸ Targeting both simultaneously interrupts the self-perpetuating cycle more effectively than addressing either condition alone.

Regaining Control

With targeted interventions, men can restore hormone balance, reduce body fat, preserve muscle, and improve both metabolic and sexual health. To know if your weight puts you at risk for testosterone deficiency or related health issues, calculating your BMI, measuring waist circumference, getting precise assessments, and discussing testosterone levels with a healthcare provider are practical first steps.

For men with obesity and low testosterone, combining lifestyle changes with medical therapies like testosterone replacement offers the greatest potential to interrupt the effects that they have on each other. Even modest weight loss, when paired with targeted hormonal support, can help restore vitality, enhance sexual function, and lay the groundwork for long-term health.

Dr. Kapadia helps men address hormone imbalances, metabolic roadblocks, and lifestyle factors to help them regain control over their health, energy, and confidence. Schedule a consultation so you can start seeing everyday improvements in your sexual wellness, vitality, and stamina.

Note: TTh is not recommended for men without symptomatic hypogonadism, and potential risks, including fertility issues and sleep apnea, must be considered. Speak with a qualified health practitioner before beginning hormone therapy or engaging in new lifestyle modifications, especially if you have underlying health conditions.

Resources:

  1. Harvard Health Publishing. (2011, March 1). Obesity: Unhealthy and unmanly. Harvard Health; Harvard Health Publishing | Harvard Medical School. https://www.health.harvard.edu/mens-health/obesity-unhealthy-and-unmanly.
  2. Varnum, A. A., Pozzi, E., Deebel, N. A., Evans, A., Eid, N., Sadeghi-Nejad, H., & Ramasamy, R. (2023). Impact of GLP-1 Agonists on Male Reproductive Health—A Narrative Review. Medicina, 60(1). https://doi.org/10.3390/medicina60010050.
  3. Caliber, M., & Saad, F. (2020). Testosterone Therapy for Prevention and Treatment of Obesity in Men. Androgens: Clinical Research and Therapeutics, 1(1). https://doi.org/10.1089/andro.2020.0010.
  4. Rajfer J. (2000). Relationship between testosterone and erectile dysfunction. Reviews in urology, 2(2), 122–128. PMID: 16985751.
  5. Harvard Health Publishing. (2011, March 1). Obesity: Unhealthy and unmanly. Harvard Health; Harvard Health Publishing | Harvard Medical School. https://www.health.harvard.edu/mens-health/obesity-unhealthy-and-unmanly.
  6. Caliber, M., & Saad, F. (2020). Testosterone Therapy for Prevention and Treatment of Obesity in Men. Androgens: Clinical Research and Therapeutics, 1(1). https://doi.org/10.1089/andro.2020.0010.
  7. Kelly, D. M., & Jones, T. H. (2015). Testosterone and obesity. Obesity reviews : an official journal of the International Association for the Study of Obesity, 16(7), 581–606. https://doi.org/10.1111/obr.12282.
  8. Caliber, M., & Saad, F. (2020). Testosterone Therapy for Prevention and Treatment of Obesity in Men. Androgens: Clinical Research and Therapeutics, 1(1). https://doi.org/10.1089/andro.2020.0010.

Fuel Your Fire: Naturally Boosting Testosterone

Posted on by Akash Kapadia, MD in ,

40% of men over 45 experience clinically low testosterone.¹

Sounds straightforward enough, but think about what this hormone actually powers: energy, muscle, motivation, mood, and libido. That statistic means 40% of men could also be feeling drained and fatigued, struggling to stay strong, noticing a lag in sex drive, or experiencing fewer spontaneous erections.

Many men turn to prescriptions, a viable option, but there’s also a growing interest in natural ways to keep testosterone in a healthy range. From lifestyle factors such as diet, sleep, exercise, and stress management to herbs, micronutrients, and specific foods, several practical strategies can help maintain (or even modestly boost) testosterone production.

Food

What you eat ripples through nearly every body system, including the glands and pathways that regulate testosterone. A healthy diet is one of the most effective methods to maintain hormone balance. Nutrient-dense meals give your body the raw materials it needs, while restrictive or unbalanced diets can throw your whole system off-kilter.

Two minerals in particular, zinc and magnesium, play outsized roles in testosterone synthesis. Zinc is involved in both the production and secretion of luteinizing hormone (LH), the chemical messenger that signals your testes to make testosterone. It also helps convert testosterone into its more potent cousin, dihydrotestosterone (DHT). When zinc levels are low, testosterone levels tend to follow. Studies show that supplementation with zinc in zinc-deficient men can raise both total and free testosterone.²

When paired with exercise, magnesium supplementation has also been shown to increase testosterone, likely by reducing oxidative stress and inflammation (which can damage testosterone-producing Leydig cells) and by increasing the availability of more bioavailable hormone. In studies combining exercise and magnesium supplementation, testosterone (both free and total) was elevated.²

Taking a multivitamin tailored to your gender and age typically provides most of the essential minerals and vitamins you need, but additional supplementation may become necessary in some cases. Vitamin D, iron, calcium, and B vitamins are common gaps, and addressing them can make a measurable difference in how your body functions.

Most people think of vitamin D as “the bone vitamin,” and that’s true. It supports healthy skeletal bone, but it’s actually more like a hormone that influences the whole body. Receptors for vitamin D are found throughout the body, including in penile tissue, which means it can directly affect sexual health. When vitamin D binds to specific receptors, it helps regulate thousands of genes that guide how cells grow, repair, and function.³

In practical terms, being low in vitamin D doesn’t just weaken bones – it can also interfere with testosterone production and healthy erectile function. Low vitamin D often goes hand-in-hand with low testosterone, and long-term supplementation in deficient men has been shown to raise both total and free testosterone.⁴

Whole foods provide essential vitamins that support testosterone naturally, and if you need a boost, the plate is a good place to start. Here are some foods that pack hormone-friendly nutrients:

  • Oysters, beef, pumpkin seeds, chickpeas – rich in zinc
  • Spinach, almonds, dark chocolate, and avocados – sources of magnesium
  • Egg yolks, salmon, fortified dairy – supply vitamin D
  • Olive oil, nuts, fatty fish – provide healthy fats for hormone production
  • Pomegranate, berries, and cruciferous vegetables (like broccoli) – support antioxidant balance and hormone metabolism

One last mention on diet: We often hear about the dangers of high cholesterol and being mindful of keeping it low – if your numbers are elevated, that’s generally sound advice. But if your cholesterol is already in a healthy range, going ultra-low-fat might actually backfire.

Cholesterol is the raw material from which testosterone and other steroid hormones are made. Diets too low in fat can limit cholesterol production (hence testosterone), while higher-fat approaches (including ketogenic diets) have been linked to increased testosterone, especially in men who strength train.⁴ Chronic calorie restriction or pushing your body too hard without proper nutrition can suppress LH signaling and lower hormone output.

Herbs

Certain herbs, plant extracts, and phytochemicals (naturally occurring compounds in plants) may help preserve testosterone by limiting its conversion to estrogen and gently nudging hormone pathways in the right direction.⁴

Many of these come from traditional medicine, including plants in the Araliaceae family (like ginseng) and Zingiberaceae species (such as ginger and turmeric), along with fruits like mangosteen, grape seeds, white button mushrooms, and even red wine. (Easy does it on the red wine; alcohol intake can wipe out nutrients your body needs to stay healthy.)

For example, mangosteen supplementation in one study increased free testosterone levels and improved strength outcomes compared to a placebo.⁴ Certain flavonoids – apigenin in parsley and chamomile, chrysin in honey, catechins in cocoa and prune juice, and resveratrol in red wine – also show promise in supporting testosterone by acting as natural aromatase inhibitors (substances that help prevent the conversion of testosterone into estrogen).

Other herbs often talked about for testosterone support include puncture vine (Tribulus terrestris), fenugreek (Trigonella foenum-graecum), ashwagandha (Withania somnifera), Tongkat ali (Eurycoma longifolia), and ginseng.⁵ It’s hypothesized that they work by stimulating the glands that produce testosterone, improving responsiveness to luteinizing hormone (LH), reducing stress and inflammation, or protecting testicular cells from oxidative damage. Some men notice appreciable changes in energy, libido, or strength, while others see minimal results. Quality, dose, and individual differences like age, baseline hormone levels, and overall health all contribute to the effect of supplements and lifestyle changes.

While encouraging, most of this research is still preliminary. Many studies are done in vitro (test-tube or cell culture) or in animals rather than humans. Human studies tend to be small, and the real-world effects depend on dose, preparation quality, bioavailability, and baseline nutritional or hormonal status. These herbs show promise, particularly for men with low testosterone or stress, but they’re not guaranteed fixes. Larger, high-quality studies are needed to clarify which herbs work best and in what amounts. Most importantly, don’t start any supplementation regimen without your doctor’s oversight.

Sleep

Sleep is essential for many of the body’s mechanisms to function properly, and hormones are no exception. When we are sleep deprived, we also become hormone, nutrient, and energy deprived.

In one study, 10 healthy young men were observed sleeping 10 hours per night for three nights. Then, their sleep was restricted to only five hours per night for eight consecutive nights. Researchers observed that daytime testosterone levels dropped by 10-15% compared to when individuals were better rested, particularly in the afternoon and evening. Participants also reported feeling less energetic and motivated when experiencing reduced sleep. Interestingly, the testosterone decline occurred without a significant change in cortisol (a stress hormone), suggesting that sleep loss itself (not just stress) directly lowers testosterone.⁶ (Although cortisol does affect hormone levels, as we’ll see soon.)

Missing sleep, even a little, lowers testosterone production – if sleep is cut short, disrupted, fragmented, or of poor quality, testosterone tends to fall. Sleep disorders, like obstructive sleep apnea (OSA), can make this worse.⁷ In OSA, the airway collapses repeatedly during the night, interrupting deep sleep and reducing oxygen levels. This repeated disturbance can significantly blunt testosterone release and is often compounded by excess body weight.

Even if you’re technically “in bed” long enough, broken or shallow sleep keeps testosterone from reaching normal peaks overnight. Research also suggests that testosterone is most sensitive to the amount of deep, restorative sleep (stages 3 and 4 of non-REM).⁷ Prioritizing both sleep quantity and quality is one of the most effective ways to support testosterone and overall vitality naturally.

Exercise

How do different measures of fitness and body composition relate to total testosterone (TT) levels? Researchers explored this by looking at 87 men, measuring their body fat percentage, cardiorespiratory fitness, muscle strength, agility, and flexibility.⁸

Here’s what they found: men with higher amounts of fat, particularly abdominal fat, tended to have lower testosterone, and those with better cardiorespiratory fitness (how efficiently the heart and lungs work) had higher testosterone.⁸

Escalating aerobic exercise with activities that improve your heart and lung capacity and lowering body fat (with emphasis on belly fat) appear to be some of the most effective natural strategies for raising testosterone, especially in men with erectile dysfunction (ED).⁸ Resistance training (lifting weights) also helps, but combined aerobic and strength training with trimming the midsection delivers a bigger testosterone boost than lifting alone.

Stress

Chronic stress takes a toll on nearly every system in the body, and over time, it can quietly chip away at testosterone levels. Animal studies show that prolonged stress causes the testosterone-producing Leydig cells in the testes to falter, shrinking in size and output. The main culprit is cortisol, the body’s primary stress hormone, which interferes with the biochemical steps needed to make testosterone.⁹

Chronic stress also alters how Leydig cells respond to luteinizing hormone (LH), one of the primary signals the body uses to instruct the testes to produce testosterone. When that communication is disrupted, the cellular machinery can’t properly convert raw materials into testosterone. As this process drags on, baseline testosterone secretion decreases, resulting in consistently lower levels than they should be.

Additionally, chronic stress tends to accumulate through effects such as increased inflammation, oxidative stress (where cells are damaged by reactive molecules), and potential decreases in eating, sleep, or energy availability, all of which can further impair testosterone production.

There is a caveat worth mentioning about the difference between acute stress and chronic stress. Acute stress puts our system into action and can actually be healthy. In a study where researchers measured testosterone in participants’ saliva at baseline and during exam stress, they found that short-term psychological stress, like facing a test, might raise testosterone in men (at least temporarily). But how this happens depends on who you are, your personality, how much you dwell on things, and how well you handle your emotions.¹⁰

That said, if you’re under constant stress, your testosterone is likely to drop, not just temporarily but in a more lasting way. Managing stress through good sleep, realistic workloads, relaxation practices, therapy, or lifestyle changes can help maintain healthier, more stable testosterone levels over time.

Finding Balance

Optimizing testosterone takes seeing the big picture and creating a healthy balance in life. Diet, sleep, exercise, and stress management all work together to support hormone production, and even small, consistent changes can make a significant difference in how you feel day-to-day.

It’s important to note that natural products are not a substitute for medical advice, and they aren’t risk-free. Some can interact with prescription medications or existing health conditions in ways that may not seem obvious – don’t self-prescribe or mix therapies without guidance.

The best step you can take is to have an open conversation with your urologist. A specialist can evaluate your hormone levels, review your current medications, and help you choose safe and effective strategies—whether pharmaceutical, natural, or a combination.

For professional guidance on naturally boosting testosterone and combining lifestyle approaches with medical care, schedule an appointment with Dr. Kapadia. Together, we’ll develop a practical plan tailored to your goals.

References:

  1. Sizar, Omeed, et al. “Male Hypogonadism.” PubMed, StatPearls Publishing, 25 Feb. 2024, www.ncbi.nlm.nih.gov/books/NBK532933/.
  2. Zamir, A., Ben-Zeev, T., & Hoffman, J. R. (2021). Manipulation of Dietary Intake on Changes in Circulating Testosterone Concentrations. Nutrients, 13(10), 3375. https://doi.org/10.3390/nu13103375.
  3. Canguven, O., & Al Malki, A. H. (2021). Vitamin D and Male Erectile Function: An Updated Review. The world journal of men’s health, 39(1), 31–37. https://doi.org/10.5534/wjmh.190151.
  4. Zamir, A., Ben-Zeev, T., & Hoffman, J. R. (2021). Manipulation of Dietary Intake on Changes in Circulating Testosterone Concentrations. Nutrients, 13(10), 3375. https://doi.org/10.3390/nu13103375.
  5. Smith, S. J., Lopresti, A. L., Teo, S. Y. M., & Fairchild, T. J. (2021). Examining the Effects of Herbs on Testosterone Concentrations in Men: A Systematic Review. Advances in nutrition (Bethesda, Md.), 12(3), 744–765. https://doi.org/10.1093/advances/nmaa134.
  6. Leproult, R., & Van Cauter, E. (2011). Effect of 1 week of sleep restriction on testosterone levels in young healthy men. JAMA, 305(21), 2173–2174. https://doi.org/10.1001/jama.2011.710.
  7. Wittert G. (2014). The relationship between sleep disorders and testosterone in men. Asian journal of andrology, 16(2), 262–265. https://doi.org/10.4103/1008-682X.122586.
  8. Yeo, J. K., Cho, S. I., Park, S. G., Jo, S., Ha, J. K., Lee, J. W., Cho, S. Y., & Park, M. G. (2018). Which Exercise Is Better for Increasing Serum Testosterone Levels in Patients with Erectile Dysfunction?. The world journal of men’s health, 36(2), 147–152. https://doi.org/10.5534/wjmh.17030.
  9. Xiong, X., Wu, Q., Zhang, L., Gao, S., Li, R., Han, L., Fan, M., Wang, M., Liu, L., Wang, X., Zhang, C., Xin, Y., Li, Z., Huang, C., & Yang, J. (2022). Chronic stress inhibits testosterone synthesis in Leydig cells through mitochondrial damage via Atp5a1. Journal of cellular and molecular medicine, 26(2), 354–363. https://doi.org/10.1111/jcmm.17085.
  10. Afrisham, R., Sadegh-Nejadi, S., SoliemaniFar, O., Kooti, W., Ashtary-Larky, D., Alamiri, F., Aberomand, M., Najjar-Asl, S., & Khaneh-Keshi, A. (2016). Salivary Testosterone Levels Under Psychological Stress and Its Relationship with Rumination and Five Personality Traits in Medical Students. Psychiatry investigation, 13(6), 637–643. https://doi.org/10.4306/pi.2016.13.6.637.

Low T: Patch, Pellet, Pill, or Shot

Posted on by Akash Kapadia, MD in

Man touching hormone patch on arm

Testosterone replacement therapy (TRT) is having a moment. Scroll through social media, tune into late-night radio, or walk past a strip mall, and odds are you’ll spot an ad or clinic offering to “boost your T.” But behind the hype is a decades-deep history of clinical use and an evolving toolkit designed to restore balance for men dealing with low testosterone.

Just how many decades back did the research start? In 1889, physician Charles-Édouard Brown-Séquard injected himself with a concoction made from animal testicles, believing it rejuvenated his vitality. While his experiment was probably more alchemy than science, it sparked over a century-long exploration into testosterone’s potential. By the 1930s, testosterone had been isolated and synthesized in a lab; by the 1950s, longer-acting injections became the gold standard of therapy.¹

Since then, TRT has expanded to include intramuscular injections, transdermal gels, subdermal pellets, buccal tablets, nasal sprays, and, more recently, oral capsules, each with unique pharmacokinetics and benefits.

We’ve come a long way, with options that are more ethical, advanced, accessible, and personalized – but they also require thoughtful guidance. In the following sections, we’ll dip into modes of testosterone delivery, how they work, and what patients can expect from each one.

Modern Options

Testosterone, the primary male sex hormone, plays a central role in sexual development, reproductive function, muscle mass, bone density, and mood regulation. When levels dip too low – a condition known as hypogonadism – men may experience symptoms ranging from fatigue and depression to erectile dysfunction, infertility, and reduced lean body mass. In cases where testosterone is measurably low (typically under 250 nanograms per deciliter), clinicians may recommend therapy to bring levels back into a normal physiological range.

While testosterone levels naturally decline with age, dropping about 1% per year starting around age 30, not all men develop symptoms. That’s why treatment isn’t based solely on numbers, but on the presence of real, disruptive symptoms supported by lab work and a legitimate medical evaluation.

The FDA-approved options on the market today offer flexibility in how testosterone is delivered, how often it’s dosed, and how steadily it’s absorbed. Each route comes with its rhythm, risks, and appeal depending on your lifestyle, goals, and medical profile.

Subdermal Pellets

Testosterone pellets are tiny cylinders placed just under the skin (usually in the upper buttock or hip area) during a quick in-office procedure. Once implanted, they slowly release testosterone over several months by diffusing steadily into the surrounding tissue and bloodstream.

Why people like them: They’re hands-off after insertion. No daily doses, no weekly shots, and most people get them reinserted every 3 to 6 months. Pellets are popular for their consistency, eliminating the need for self-administration or adhering to a strict daily schedule.

What to consider: The timing of symptom relief and when levels start to taper can vary. Some men feel great right away, while others may experience a lag as hormone levels build. Toward the end of the dosing cycle, it’s common for symptoms to return as the pellets lose potency.

There’s also a small risk that the pellet may work its way out or cause skin irritation or infection at the insertion site. It doesn’t happen often, but it’s worth being informed when making a decision.

Intramuscular Injections

Testosterone injections have been around longer than any of the other methods of delivery. They’re typically administered into a large muscle (like the glute or thigh) every 1 to 2 weeks, depending on the formulation or brand.

Why people like them: Injections deliver a full dose of testosterone directly into the bloodstream, which can bring fast symptom relief. Many men appreciate the simplicity and cost-effectiveness, especially when self-administering becomes routine.

What to consider: Levels can spike and crash between injections, leading to mood swings or fluctuations in energy. Some men find the needle aspect intimidating at first, but with a little practice (or help from a provider), it usually becomes second nature.

Transdermal Gels and Patches

Transdermal testosterone is delivered through the skin in two forms: gels and patches. Gels are applied once daily to clean, dry skin – typically on the shoulders, upper arms, or abdomen – while patches are worn continuously, usually on the back, thigh, or upper arm, and replaced every 24 hours.

Why people like them: Both gels and patches offer a consistent, daily dose of testosterone that closely mimics the body’s natural hormone cycle, offering steady absorption and bypassing the peaks and valleys commonly associated with intramuscular injections. Gels absorb quickly with minimal mess, and patches are easy to use once you get into a routine – no needles or office visits required for administration.

What to consider: Transdermal methods require careful hand-washing and drying time before dressing to avoid skin transfer to others, especially children or partners. Patches can sometimes cause mild skin irritation or redness at the application site, and may not stick as well in hot or humid climates. Still, many men find these options easy to integrate into daily life with a bit of trial and error, and rotating where the patch is applied helps to reduce skin irritation.

Oral Capsules

Several oral testosterone options have been FDA-approved in the last five years. In the past, oral testosterone was discontinued due to concerns about liver toxicity. But newer formulations have solved that issue by bypassing the liver entirely – they’re absorbed through the lymphatic system instead, making them a safer option for long-term use.

Why people like them: Oral testosterone is straightforward and needle-free. It’s in a form most of us are familiar with, and dosing is usually twice a day with food. There’s no need for patches, gels, or procedures, and it avoids the skin-to-skin transfer risks associated with topical products.

What to consider: Despite the convenience, hormone levels can sometimes fluctuate compared to other delivery methods until you get a rhythm going. Some men also experience gastrointestinal side effects, and for those with cardiovascular concerns, you’ll need to work more closely with your provider.

Buccal Tablets

These are small, sticky tablets that you press against your upper gum twice a day, where they slowly dissolve and deliver testosterone through the tissues in your mouth.

Why people like them: They’re discreet, they don’t require needles or gels, and they don’t come with the peaks and valleys of some other methods. Once they’re in place, you can go about your day with a steady release of testosterone.

What to consider: They can take a little getting used to. Some men notice a strange taste and potential gum irritation. The need to apply it twice a day like clockwork creates a steady influx of the medication, so missing a dose can throw off the constant flow your body gets used to.

Nasal Spray

Nasal delivery is a fast-absorbing option for men seeking more frequent microdoses – one spray in each nostril, three times a day. It might seem odd to take a hormone through your nose, but the nasal lining gives testosterone a direct and efficient path to your bloodstream.

Why people like it: It’s a good option if you’re looking for something less invasive that keeps hormone levels from swinging too much, and it has the advantage of minimal systemic buildup, meaning there’s less chance of having to dial back the dose to avoid off-target effects from elevated testosterone levels.

What to consider: Because it requires multiple applications a day, it might not suit everyone’s schedule. Nasal irritation or a stuffy nose are potential side effects, and the delivery can be impacted by congestion, especially in allergy season.

The Next Move

Research shows that most delivery methods are equally effective in raising testosterone to therapeutic levels and improving body composition, mood, and sexual function.² What differs most is the side effect profile and how well each method fits into your daily life. Other medications you take will also be a deciding factor.

With so many options on the market, it can be tricky to navigate legitimate therapy and fly-by-night online distributors. That’s why it’s essential to work with a knowledgeable and experienced provider who understands the nuances of hormone therapy and can tailor treatment based on your full medical picture.

If you’re feeling a drop in energy, a dip in sex drive, or noticing changes in mood or muscle tone, Dr. Kapadia specializes in personalized hormone therapy that prioritizes safety, efficacy, and your preferences. Reach out to schedule a consultation and start feeling like yourself again.

References:

  1. Figueiredo, M. G., Gagliano-Jucá, T., & Basaria, S. (2022). Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option. The Journal of clinical endocrinology and metabolism, 107(3), 614–626. https://doi.org/10.1210/clinem/dgab772.
  2. Ahmad, S. W., Molfetto, G., Montoya, D., & Camero, A. (2022). Is Oral Testosterone the New Frontier of Testosterone Replacement Therapy?. Cureus, 14(8), e27796. https://doi.org/10.7759/cureus.27796.

TESE, Micro-TESE, and Low Testosterone

Posted on by Akash Kapadia, MD in ,

Woman on husbands back with arms around chest, both smiling

TESEs were first performed in the early 1990s and provided men with a fertility option even if semen analysis showed no sperm – known as azoospermia. This ushered in an era of male fertility options that allowed urologists to retrieve sperm in about 30% of men, ultimately resulting in about 25% of men being able to become fathers. With 1% or so of all American men not having usable sperm in their semen, this was a major step forward.

Around the same time, we began to understand the landscape of male versus female infertility, and we now know that about a third of all infertility issues can be attributed to the male patient, a third to the female patient, and a third to both. So, finding a way to improve male fertility has addressed a key concern of couples struggling to conceive.

The TESE and even micro-TESE is an invasive procedure used for sperm extraction from the testes. Both require cutting into the testicle, at which point the urologic surgeon tests areas of the testicle for sperm. If sperm are found, they are extracted for later insemination.

Continue reading “TESE, Micro-TESE, and Low Testosterone” →

What to Know About Testicular Mapping

Posted on by Akash Kapadia, MD in , ,

Older man smiling in woods sitting on log

While there’s plenty we don’t know, we have learned a lot about male fertility and reproduction over the past few decades. One of the most exciting areas of research and advancement has been in the management of male fertility concerns. Nonobstructive azoospermia was at one time considered difficult or impossible to treat, yet now, many men with no detectable sperm in their semen have become fathers. Today, there are several sperm extraction techniques available to these men, but most are invasive. As such, there has been a need for minimally invasive diagnostics to see whether sperm can be found in the testes.

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Can Tongkat Ali Boost My Testosterone? A Urologist’s Perspective

Posted on by Akash Kapadia, MD in , ,

Disclaimer: We want to address Tongkat Ali due to its recent and sudden rise in popularity, however, it is important to note that these studies are poorly designed and lack high-quality data. We can’t be sure of the benefits of Tongkat Ali until they are shown in well-designed clinical trials. Patients should consult with a physician regarding safety before starting any supplement regimen.

man dumping Tongkat Ali supplement from bottle into hand

Tongkat Ali or Longjack, an herb found in Southeast Asia and commonly used as part of traditional holistic medicine there, has risen in popularity due to claims about its effectiveness in increasing testosterone, reducing stress, and potentially even boosting male fertility. Various podcasters, including Joe Rogan and Professor of Neurobiology at Stanford University Andrew Huberman, have discussed this herb in depth. They posit that taking Tongkat Ali boosts antioxidant levels in the body to fight free radicals while normalizing certain hormones like testosterone and Cortisol. Do these claims hold water? Let’s dive in.

Before we evaluate each of these claims, it is important to note that the FDA does not oversee supplements. Therefore, you must do your due diligence about which supplements to buy, as their purity and concentrations can vary. Safety should be your primary concern. Continue reading “Can Tongkat Ali Boost My Testosterone? A Urologist’s Perspective” →