Testosterone replacement therapy can help men (with low testosterone) build muscle mass, lose weight and feel better overall.
Does that mean that every man should use testosterone?
But it does mean that because of the potential benefits, it's worth looking into if you are suffering from any of the symptoms that may be associated with low testosterone.
In this case study, I'm going to walk you through the treatment of a 61-year-old patient of mine who was able to lose 20 pounds of fat mass while gaining 20 pounds of muscle mass through proper testosterone replacement therapy.
You will also find out how to determine if testosterone replacement therapy is worth considering in your case, the symptoms of low testosterone and how to properly and safely replace testosterone if indicated.
You can see his 3 months before and after pictures of this patient below:
Testosterone Replacement Therapy in Men: What You Need to Know
To start with we need to talk about weight loss and testosterone.
One of the questions I frequently get asked is this:
Does testosterone help with weight loss?
The answer to this question is yes, it absolutely can help with weight loss.
Studies have shown that testosterone replacement therapy can help men not only lose weight but keep the weight off (1).
Testosterone in men is important for the maintenance and development of skeletal muscle mass.
It also plays a role in cardiovascular health, mood, energy levels, and even libido.
Testosterone, as it relates to the quality of life in men (2), is of utmost importance.
I have countless stories of men who start testosterone and have improved weight loss, more energy, better sex lives and an improvement in overall quality of life (3).
So why isn't testosterone discussed at your primary care office visit?
Why does testosterone replacement therapy get a bad name?
Why do most people equate testosterone with bodybuilders?
It turns out there is a general lack of knowledge as it relates to testosterone replacement among many physicians (and even patients).
The truth is that the testosterone replacement therapy I am referring to in this case study is the replacement of testosterone to normal and physiologic levels that a 20-30-year-old young man would experience in his life.
It is not the supraphysiologic levels that result in testicular atrophy or other negative side effects.
When you replace testosterone in physiologic and normal doses there are many benefits and hardly any negative side effects (aside from maybe some acne on occasion).
The doses that bodybuilders use are often 2-5x higher than normal physiologic levels and may cause negative side effects like infertility later in life.
We are not talking about this kind of testosterone dosing here.
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How does Testosterone Help with Weight Loss?
So now that that is out of the way, how does testosterone impact weight?
Through several mechanisms...
Testosterone helps men to build and maintain muscle mass (4).
Increasing muscle mass in the male body results in a baseline increase in resting energy expenditure or resting metabolic rate.
You probably know this as your "metabolism".
The higher your metabolism, the more calories you burn, the more weight you lose.
Testosterone replacement helps to lower leptin levels (5).
Leptin is the hormone secreted by fat cells (leptin resistance is a consequence of weight gain) and impacts both metabolism and body composition.
The higher leptin levels get the more difficult it is to lose weight and the easier it is to gain weight.
As leptin levels increase testosterone decreases and men experience many of the symptoms of low testosterone.
As testosterone levels are replaced leptin levels fall, men lose the excess weight they were carrying and their symptoms subside.
The inverse correlation between leptin and testosterone may explain why men have such a robust reaction to testosterone replacement therapy.
Testosterone plays a role in insulin signaling and insulin sensitivity (6).
Insulin is another hormone that directly leads to weight gain (7) in both men and women.
Insulin resistance is a very common cause of weight gain and testosterone and insulin have an inverse relationship with one another.
As insulin levels increase testosterone levels decrease.
Men who are overweight with large abdomens tend to have high insulin levels.
Testosterone plays a role in insulin signaling and as testosterone levels fall it creates an environment which allows for insulin resistance to develop.
As testosterone levels are replaced and weight is lost, insulin signaling improves.
So now that we know how testosterone helps with weight loss, how do you know if it will help you?
Symptoms of Low Testosterone in Men
Men with low testosterone typically present with one or more of the following symptoms:
- Decreased energy or fatigue
- Difficulty with losing weight, or not able to lose weight like you used to
- Changes in sexual function including the inability to maintain an erection
- Loss of muscle mass or muscle tone and difficulty in building or maintaining muscle mass
- Changes in mood, including flat affect (may also manifest as depression)
- Increased recovery time after joint/muscle injury
- Reduced stamina during workouts or lifting
- Overall reduction in quality of life
It's important to realize that many of these symptoms are non-specific and there is a crossover between other hormone imbalances.
Having said that, most men do know when something is "off".
If you fall into any of the above categories or have just been experiencing new symptoms for your body it would be reasonable to assess your hormones via blood testing.
It's also worth mentioning that nowadays men as young as 30 can have low testosterone levels.
While it is certainly more common for men in their 40-50's to have low testosterone it is now much more common in younger men as well.
Benefits of Testosterone Supplementation in Men
The benefits of replacing testosterone vary from person to person and largely depend on your presenting symptoms.
In this particular patient he experienced the following improvements:
- Increased muscle mass (he gained 20+ pounds of muscle mass over 3 months)
- Fat mass loss (while his weight actually increased because of muscle mass, his pants/clothes fit tighter)
- Improved recovery time after sports injuries (this patient was physically active prior to testosterone replacement and was an avid runner with the occasional muscle sprain/twisted ankle)
- Increased and sustained energy levels throughout the day (as a teacher he is now able to get through his entire workday without dips in energy levels)
- Improved mood, decreased irritability and reduced symptoms of depression (having suffered from depression throughout his life he noticed that his overall mood was "lighter")
In my experience, most men (around 80%+) will experience positive side effects throughout treatment.
If a comprehensive approach is taken to balance hormones then that number increases dramatically.
It's important to realize that these are the subjective improvements in symptoms and don't represent changes to biomedical markers such as improvement in cholesterol, reduced blood sugar, and reduced insulin levels.
These symptoms were also accompanied by many positive changes in his lab work.
Testing for Low Testosterone + Other Hormones in Men
In order to get proper testosterone replacement, you will likely need to seek help from a knowledgeable physician or another provider.
Many primary care providers and general practitioners may not have the knowledge necessary to replace and/or monitor testosterone replacement therapy.
Part of your workup should include a comprehensive hormone and basic blood panel to evaluate hormone levels and other biomedical markers.
If you are interested in optimizing your testosterone levels (and other hormones) for weight loss then I would recommend starting with this panel:
- Testosterone free and total: Check both of these markers but focus on total testosterone initially. Total testosterone in a healthy male should be > 700 (some even need higher levels), most men with low testosterone present with testosterone levels between 150-300 and these are suboptimal and may be consistent with low T symptoms.
- Estradiol: Testosterone can convert to estrogens which is why monitoring this is important, as estradiol increases men may experience: gynecomastia (breast tissue growth), erectile dysfunction and/or an increase in emotions. This should be less than 30.
- Sex hormone binding globulin: This protein binds testosterone making less available for use, both estrogen and thyroid hormone increase this marker so SHBG should be monitored on testosterone and/or thyroid hormone replacement. SHBG in men should be < 20-30.
- Complete thyroid panel: This includes TSH, free T3, reverse T3, total T3, and thyroid antibodies. Conditions that lower testosterone also tends to lower thyroid hormone and both are required for optimal function.
- Lipid panel: The basic cholesterol panel is limited and for assessing cardiovascular risk correctly you will want advanced cardiac tests like apolipoprotein B and/or an NMR lipoprofile. The basic lipid panel is helpful for assessing your degree of insulin resistance via the HDL/triglyceride ratio, however (and it is easy to order).
- Fasting insulin: This value should be < 5 in the fasted state, please note that normal fasting insulin levels do not necessarily indicate normal postprandial levels and these levels are more sensitive than fasting levels. However, elevated fasting insulin is indicative of insulin resistance.
- Fasting glucose: Optimal levels should be < 80.
- Fasting Leptin: Optimal levels should be < 10 (anything higher in the setting of obesity indicates leptin resistance).
As you can see from above each hormone must be evaluated in the setting of the other hormones and put into the context of your symptoms.
It's not as straightforward as "this is high, this is low so take this".
Having said that, if you are a male looking to optimize your testosterone levels you will want to focus on both estradiol and total testosterone.
Estradiol should be low (less than 30) and total testosterone should be 700+ (with standard reference ranges of 300-900).
Focusing on these values won't give you the best results possible but it makes the interpretation manageable for physicians who don't focus on hormone replacement therapy.
Just realize that this approach will not focus on optimal results.
To get the kind of results you see in this case study you will want to take a more comprehensive approach.
Below I will dissect the pertinent labs of this patient...
Case Study: Lab Results + Treatment
Let's go over the labs of this particular patient to give you an idea of what it takes (we will also go over his treatment below as well).
Let's start with testosterone:
As mentioned previously optimal testosterone levels are generally 700+.
This patients total testosterone is 797 with a range of 250-1100.
Because this patient is using weekly injections of testosterone cypionate we checked this value on day 6 prior to his next schedule testosterone injection.
Injectable testosterone reaches a peak on day 2-3 so this value is likely higher if we were to check it earlier in the week, but he was doing quite well on these levels.
As a reference, his starting total testosterone was 217 (labs not shown), so this represents a significant improvement from baseline.
As I mentioned previously this patient was also suffering from fatigue, low energy, mood changes and especially depression.
Further analysis of his labs showed some interesting findings...
His thyroid studies were sub-optimal.
His TSH was > 2.5 (optimal levels are less than 2.0), and both free T3 and T4 were in the low end of the optimal reference range.
This was probably a minor problem caused by poor nutrition, nutrient deficiencies, and other lifestyle factors - but will still certainly play a role in his overall energy levels and metabolism.
His iron studies were low...
While he wasn't outright anemic, low iron can absolutely contribute to low energy and sub-optimal thyroid function.
In addition to low iron, he also showed positive markers to both tissue transglutaminase and gliadin peptide antibody.
These markers together with the malabsorption of iron (and vitamin B12 though not shown) do indicate intestinal damage from a likely autoimmune source of Celiac's disease.
What's interesting is that these markers were never checked previously and this patient didn't necessarily complain of gastrointestinal issues.
Data has shown that many patients with Celiac's disease actually present with extraintestinal symptoms (8) including iron deficiency and mood-related changes.
Because of the resolution of this patient's depressive symptoms and mood changes, it's hard to say for sure what was causing them (as both testosterone and gluten was removed from his diet), but it is an interesting connection.
The replacement of iron and the removal of gluten probably helped to improve the body composition of this particular patient (in addition to testosterone replacement therapy).
This does highlight the importance of a full workout to ensure maximum results, and problems like this may explain why some male patients don't get the same results as other male patients.
But what about weight gain? What metabolic issue was contributing to this patient's inability to lose weight?
We need to look no further than fasting glucose:
This patient's fasting glucose (14-hour fasting glucose) of 105 indicates some degree of insulin resistance. This in spite of a relatively normal fasting insulin of 6.
The management and treatment of this value helped the patient significantly reduce his fat mass while simultaneously building muscle mass.
Complete treatment plan review:
- Testosterone replacement therapy with Testosterone cypionate injections once every 7 days (his preference based on price)
- HCG Injections to prevent testicular atrophy and to provide a boost to testosterone levels throughout the week
- T3 (Cytomel) to boost thyroid function and help reverse insulin resistance - also to improve mood
- Gluten-free diet due to elevated antibodies
- Replacement of nutrient deficiencies including iron, vitamin B12, adrenal support, Vitamin D3, and Vitamin K2
- Lifestyle changes to promote insulin sensitivity
The combination of these therapies resulted in the 3 months after picture outlined above which included 20 pounds of fat mass lost and over 20+ pounds of muscle mass gained in a 61-year-old male!
What's even better is that this isn't an isolated case.
When you apply these rules to other patients and take a thoughtful and thorough approach to hormone management the results are often impressive.
But the question remains:
Should you use Testosterone? Recap + Final Thoughts
This is a great question and really depends on your individual situation.
What I can tell you is this:
Testosterone replacement therapy (if used appropriately and in physiologic dosages) has the potential for dramatically increasing the quality of life in male patients.
The changes may include an overall improvement in mood, improvement in quality of life, and improvement in sexual performance, increased muscle mass, improved strength in the gym, etc.
And these are just the effects that you notice. What you may not notice is a reduction in your risk of cardiovascular-related mortality (9) or death from other hormone-related changes.
My recommendation is to seek out testing if you feel that something is "off" or if you relate to any of the above-mentioned signs or symptoms.
At baseline, a serum testosterone level can give you your next further steps - though remember for best results you will want a full hormone and metabolic panel.
Now it's your turn:
Are you taking using testosterone therapy?
Is it helping you with weight loss?
What other changes have you experienced (positive or negative)?
Leave your comments below!
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