How can I increase my free and total testosterone levels?

How to Increase Free and Total Testosterone Levels

Start with lifestyle modifications—specifically weight loss and increased physical activity—as these are the most evidence-based first-line interventions for raising testosterone levels, particularly in overweight or obese men. 1

First-Line Approach: Lifestyle Modifications

Weight Loss and Exercise

• All men with testosterone deficiency should receive counseling on lifestyle modifications as a primary treatment strategy. 1
• Weight loss and maintaining weight within the recommended range, combined with increased physical activity, has the potential to increase total testosterone levels and reduce associated symptoms. 1
• Vigorous physical activity is the key driver: A 12-week aerobic exercise intervention significantly increased serum total, free, and bioavailable testosterone levels in overweight/obese men, with vigorous physical activity being independently associated with testosterone increases (β=0.47, p=0.011). 2
• Increased physical activity has a greater effect than calorie restriction alone on raising testosterone levels during lifestyle modification programs. 3

Specific Recommendations

• High body mass index coupled with low testosterone increases cardiovascular risk, making weight loss programs essential, particularly when concurrent with any testosterone therapy. 1
• Regular weight-bearing exercise should be incorporated. 1
• Smoking cessation is recommended. 1

When Lifestyle Modifications Are Insufficient: Testosterone Replacement Therapy

Indications for TRT

• Consider TRT when documented testosterone deficiency persists despite lifestyle modifications and is accompanied by symptoms (decreased libido, erectile dysfunction, reduced energy, loss of muscle mass). 1
• Measure morning total testosterone (between 8-10 AM) on at least two separate occasions. 1
• Also measure free testosterone by equilibrium dialysis and sex hormone-binding globulin, as obesity often lowers sex hormone-binding globulin, making free testosterone assessment essential. 1

Target Testosterone Levels

• Adjust testosterone therapy dosing to achieve total testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL). 1
• Use minimal dosing necessary to reach this physiologic range. 1
• If patients don't experience symptomatic relief after reaching target levels, or remain deficient despite symptom improvement, stop testosterone therapy. 1

TRT Formulations

• Intramuscular testosterone cypionate: 50-400 mg every 2-4 weeks, adjusted based on patient response. 4
• Transdermal preparations (gel, patch): Preferred for stable day-to-day testosterone levels and avoidance of injection discomfort. 1
• Avoid 17-alpha-alkylated oral testosterone (methyltestosterone) due to liver toxicity, including abnormal liver function tests, cholestasis, and jaundice. 1

Critical Contraindications and Precautions

Absolute Contraindications

• Do NOT prescribe exogenous testosterone therapy to men currently trying to conceive, as it interrupts spermatogenesis and causes severe oligospermia or azoospermia. 1

Relative Contraindications

• Wait 3-6 months after cardiovascular events (myocardial infarction, stroke) before initiating testosterone therapy. 1
• Counsel patients that current evidence does not definitively demonstrate whether testosterone therapy increases or decreases cardiovascular event risk. 1
• Men on testosterone therapy should report cardiovascular symptoms (chest pain, shortness of breath, dizziness, transient loss of consciousness) during follow-up. 1

Alternative Strategies for Men Seeking Fertility

For hypogonadal men wishing to maintain or achieve fertility:

• Consider off-label use of selective estrogen receptor modulators, human chorionic gonadotropin (hCG), or aromatase inhibitors to treat hypogonadal symptoms while maintaining intratesticular testosterone necessary for spermatogenesis. 5
• Natesto intranasal testosterone gel may increase serum testosterone while maintaining semen parameters due to its short-acting properties having less effect on the hypothalamus-pituitary-gonadal axis. 5
• Measure 17-hydroxyprogesterone (17-OHP) as a biomarker for intratesticular testosterone to guide therapy selection. 5

"Testosterone Boosters" and Supplements

Most over-the-counter testosterone boosters fail to increase total testosterone. 6

The few exceptions with some evidence:

• β-hydroxy β-methylbutyrate and betaine may be effective for male athletes. 6
• Eurycoma longifolia shows possible effectiveness for men with late-onset hypogonadism and healthy men. 6
• Withania somnifera shows possible effectiveness for healthy men. 6
• Vitamin D (cholecalciferol) supplementation has been studied but evidence remains mixed. 6

Monitoring During TRT

• Monitor for cardiovascular symptoms at every follow-up visit. 1
• Repeat testosterone levels to ensure target range (450-600 ng/dL) is achieved. 1
• Observational studies since 2014 have not shown an association between testosterone therapy and increased venous thromboembolism risk, despite earlier FDA warnings. 1