How to increase low testosterone levels?

How to Boost Testosterone Levels

For men with low testosterone levels, lifestyle modifications should be the first-line approach, including weight loss, increased physical activity, and improved sleep habits, before considering testosterone replacement therapy. 1, 2

Diagnosis of Low Testosterone

Before attempting to boost testosterone, proper diagnosis is essential:

• Confirm low testosterone with at least two early morning measurements showing levels <300 ng/dL
• Evaluate for symptoms including:
  • Reduced energy and endurance
  • Diminished work/physical performance
  • Fatigue and reduced motivation
  • Poor concentration and memory
  • Reduced sex drive
  • Changes in erectile function
  • Infertility

Non-Pharmacological Approaches

First-Line Interventions

1. Weight Management

   • Losing weight or maintaining healthy BMI can significantly increase total testosterone levels 1, 2
   • High BMI coupled with low testosterone increases cardiovascular risk

2. Physical Activity

   • Regular exercise, particularly resistance training, can boost testosterone levels
   • Aim for at least 150 minutes of moderate-intensity exercise weekly

3. Sleep Optimization

   • Poor sleep is associated with reduced testosterone production
   • Aim for 7-9 hours of quality sleep nightly

4. Dietary Modifications

   • Mediterranean diet may support hormonal balance 2
   • Limit alcohol consumption to less than 21 units per week 2

Supplements with Limited Evidence

Most "testosterone boosters" marketed commercially fail to increase total testosterone 3. Limited evidence supports:

• β-hydroxy β-methylbutyrate and betaine (for athletes)
• Eurycoma longifolia (possibly effective for men with late-onset hypogonadism and healthy men)
• Withania somnifera (possibly effective for healthy men)
• Punica granatum fruit rind and Theobroma cacao seed extracts (possibly effective for hypogonadism)

Pharmacological Approaches (For Diagnosed Testosterone Deficiency)

Indications for Testosterone Replacement Therapy (TRT)

• Consistently low testosterone levels (<300 ng/dL)
• Presence of symptoms affecting quality of life
• No contraindications

Contraindications for TRT

• Breast or prostate cancer
• Hematocrit >50%
• Severe untreated sleep apnea
• Severe lower urinary tract symptoms
• Uncontrolled heart failure
• Desire for current or future fertility 1, 2
• Recent cardiovascular events (within 3-6 months) 1, 2

TRT Options

1. Topical Gels/Creams

   • Applied daily to shoulders and upper arms
   • Risk of transfer to women and children requires precautions 4

2. Injections

   • Typically administered every 1-2 weeks
   • May cause fluctuations in testosterone levels

3. Patches

   • Applied daily
   • May cause skin irritation

4. Pellet Implants

   • Inserted subcutaneously every 3-6 months
   • Provides steady testosterone levels

Monitoring During TRT

• Initial follow-up: 1-2 months after starting treatment
• Subsequent monitoring: Every 3-6 months initially, then annually
• Target testosterone levels: 450-600 ng/dL (middle tertile of normal range) 1, 2
• Monitor for adverse effects:
  • Hematocrit (discontinue if >54%)
  • PSA (biopsy if >4.0 ng/mL or increases >1.0 ng/mL/year)
  • Cardiovascular symptoms
  • Sleep apnea symptoms
  • Urinary symptoms

Special Considerations

Alternative Options for Men Desiring Fertility

For men with testosterone deficiency who want to maintain fertility, consider 1:

• Human chorionic gonadotropin
• Selective estrogen receptor modulators
• Aromatase inhibitors

Cardiovascular Risk

• Current evidence is inconclusive regarding whether TRT increases or decreases cardiovascular risk 1, 2
• Men on TRT should report any cardiovascular symptoms immediately

Conclusion

Addressing low testosterone should begin with lifestyle modifications, which can often improve levels without medication. For men with confirmed testosterone deficiency not responding to lifestyle changes, TRT may be appropriate under proper medical supervision with regular monitoring for potential adverse effects.