A Number Isn't a Diagnosis

At my last physical, my doctor offered me a testosterone test. I could get one if I checked a box on the intake sheet, printed right next to the cholesterol panel and the A1C.

I didn't check it.

True, I had all the symptoms people link to low testosterone. I was tired, sleeping badly, and snapping at people who didn't deserve it, including my cats. Each one had a rational explanation, too. I was leaving a career I'd spent years building for a new one I wasn't sure would work. The appointment fell on the day before my forty-ninth birthday, at Christmastime, with all the family pressure the holidays bring. All those were enough to account for how I felt.

The test they were offering was a lone blood draw, which can't diagnose low testosterone on its own. A man who checks that box and gets a low number can leave with a diagnosis that rests on one reading.

Testosterone is made mostly in the testes, on a signal from the brain. The pituitary gland releases LH and FSH, and the testes respond. The hormone keeps sexual function, bone density, and muscle mass in working order, works alongside estradiol to do it, and also raises red blood cell production.¹

Low testosterone is a real thing. When a man’s body doesn’t do its job, he can lose sex drive, muscle, and bone density, and some might even become anemic. Fatigue, low motivation, and a low mood come with it too, but those can happen from plenty of other problems. Treatment helps. In trials, testosterone improved libido, erectile function, and sexual activity more than the placebo, raised bone density, and increased muscle mass and strength, with a smaller effect on mood and energy in older men.¹

But what is “low”? The Endocrine Society and the American Urological Association (AUA) set the line for "low" at different numbers. They agree on the process that would lead to a solid diagnosis, which is two separate morning blood draws, both low, before treatment starts.¹ ² Testosterone follows a daily rhythm and peaks early in the day, so the draw should be done in the morning. The level also bounces from one day to the next, pushed around by sleep, illness, alcohol, and stress, so the two draws should also be done on different days. About 30% of men whose first reading falls in the low range have a normal level when it's repeated, according to the Endocrine Society's guideline.¹

A low reading after a week of bad sleep looks the same as a real deficiency. Another draw on a different morning separates them. A repeat low confirms the deficiency. A normal repeat means the first result was noise, and he could have spent years on a hormone he didn't need.

The Endocrine Society uses 264 ng/dL, the bottom 2.5% of healthy, non-obese men aged 19 to 39 in a pooled study of 1,185 men.¹ ¹³ The AUA calls 300 a reasonable cutoff and says a diagnosis needs symptoms along with the number.² Labs vary too, and tests without CDC certification can read the same blood differently, so a local lab's normal range can mislead.¹

On top of it all, the same number can mean different things in different bodies. Body fat converts testosterone to estrogen, and a fatty liver and inflammation lower SHBG, the protein that carries testosterone in the blood.¹⁵ Low SHBG makes total testosterone harder to interpret, because less of it is bound. For that reason, free testosterone should be measured in men with obesity or diabetes, or when total testosterone falls between 200 and 400, according to the Endocrine Society.¹ Let’s not forget about weight. In a pooled analysis of 24 studies in men with obesity, total testosterone rose by about 80 ng/dL with a low-calorie diet and about 250 with bariatric surgery, and the amount of weight lost predicted the rise best.¹⁴ Age lowers it too, and the Endocrine Society advises against treating men 65 and older for age-related low testosterone as a routine matter.¹

If treatment begins because the first draw was low, the drug will start to suppress his own testosterone production. A man treated off one reading may or may not have been misdiagnosed. I don't know, and neither does the doctor who wrote the prescription. The check that would have settled the question didn't happen, so he has a treatment that changes his hormone levels and a diagnosis that wasn't confirmed.

These days, patients push hard for treatments. In a 2025 survey of providers who treat male hypogonadism, all of them reported at least one direct patient request for testosterone therapy in the previous six months, and 74.5% called direct-to-consumer advertising for testosterone a public health problem.³ The researchers pointed to a knowledge gap to explain why specialists confirm a diagnosis more often than primary care does.

Confirming low-T also sends the patient on another trip back to the doctor’s, and a trip like that is easy to let slide, for the patient and for the office. Since Medicare pays roughly twenty to thirty dollars for a total testosterone draw (CPT 84403), a second draw doesn’t do much for the clinic.⁴

Sinha and a team at the University of Michigan reviewed two hundred charts of men started on testosterone at Michigan Medicine between 2020 and 2025 and checked each against the full standard, which requires two morning draws, LH or FSH measured, and no medical reason to hold off on treatment.⁵ Only 12% met it. Part of the shortfall comes from contraindications, since the standard excludes men with a medical reason to hold off and 55% of the cohort had obstructive sleep apnea. The coverage I could find doesn't split the other 88% into missing labs and contraindications, so I can't say how much of the shortfall is each.

Michigan Medicine is an academic medical center with endocrinologists on staff and records detailed enough for a full chart audit. A community practice with fewer of those resources has little reason to expect a better score.

Khandwala and three coauthors reviewed 193 men across four specialties and asked a narrower question. After a first low reading, did the treating physician order a second one before starting treatment?⁶ The share of patients who started without a repeat test was 45.5% in urology, 58.1% in endocrinology, 77.5% in primary care, and 88.0% in HIV medicine. Urologists were the least likely to prescribe without a second reading.

Michigan counted the full standard met about one time in eight. Khandwala found the confirmatory step missing in 45.5 to 88.0% of patients, depending on specialty. The two studies measure different things, a full workup that also screens out contraindications in one and a repeat test in the other, so you can't stack the numbers. Two teams working separately on different groups of patients both found second readings and full workups missing in many patients.

I go to a chain built around men's health. Total Men's Primary Care has dozens of locations across Texas and pushes testosterone replacement therapy hard, with tiered pricing, cash and insurance options, and in-clinic and at-home versions, four programs in all. On its website, low testosterone appears in a service list beside allergy testing and a hair-restoration treatment called Keralase, with one layout and one "book now" button for all three.

I asked them whether testosterone testing there includes a second morning draw. They gave no indication that it does.

I doubt they're doing this right. Their low testosterone page and pricing sheet don't mention a second morning draw, LH, or FSH, the steps the Endocrine Society and AUA guidelines call for. The site describes the process in one sentence, which says to run a health assessment, check the levels, and build a treatment plan if they're low.

The inside of the clinic is out of view. Without their intake forms or provider protocol, I have only what's posted publicly and the answer I got when I asked.

Treating without confirmation has costs, and they begin with the first dose. Testosterone from outside tells the brain there's already enough circulating, so the signal that tells the testes to make it goes quiet. His own production drops while he's on treatment, and the same quieting suppresses sperm production, which matters for any man who wants children in the next year or so.¹ When he stops, his body has to restart on its own.

Which form of the drug he gets changes the risks. The Depo-Testosterone label calls for 50 to 400 milligrams by injection every two to four weeks. Xyosted is a weekly autoinjector, Aveed is a shot every ten weeks, AndroGel goes on the skin daily, and pellets go under the skin. Three of these carry the FDA's strongest warning, a boxed warning. Xyosted's covers blood pressure increases, Aveed's covers pulmonary oil microembolism and anaphylaxis, which is why patients wait thirty minutes in the clinic after each dose, and AndroGel's covers children who touch the application site.⁹

Between injections, the level in his blood doesn't hold steady. It climbs after the shot and falls before the next one, and some of the testosterone converts to estradiol during the climb. A man on that curve can feel the swings as changes in mood and energy. The Depo-Testosterone label lists anxiety and depression among its adverse reactions without giving a rate, and Aveed's lists irritability, insomnia, and mood swings in 2% of men each.⁹

Testosterone also thickens the blood. One study followed 178 men for three years, and hematocrit rose above 50% in 38 of 57 men on injections (66.7%), 26 of 74 on pellets (35.1%), and 6 of 47 on gel (12.8%).¹⁰ Injections produced it sooner too, at about ten and a half months on average, against fourteen for gel. The groups were small and it's one study, so the order counts for more than the exact percentages.

Thicker blood raises clot risk in some men, and men on treatment get routine bloodwork for that reason.

A large randomized trial, TRAVERSE, put 5,246 men on testosterone gel or placebo for an average of 27 months and found testosterone no worse than placebo for major cardiac events.⁷ The trial also found more pulmonary embolism (0.9% versus 0.5%), atrial fibrillation (3.5% versus 2.4%), and acute kidney injury (2.3% versus 1.5%) in the testosterone group. After that trial, the FDA dropped the cardiovascular risk language from the boxed warnings in 2025 and added blood pressure warnings, since ambulatory blood pressure studies showed the approved products raise it.⁸ Xyosted's average rise was 3.9 over 1.5 mm Hg after twelve weeks.⁹

Side effects can start a prescribing cascade, where a drug causes a symptom, the symptom gets treated as a new problem, and a second drug joins the first.¹² Testosterone has three possible starting points. Blood pressure rises, and a doctor can add a blood pressure drug. Estradiol rises, and an aromatase inhibitor such as anastrozole can bring it down. Anxiety and irritability appear on the labels, and anxiety has its own prescriptions.

The data on those routes is thin. The AUA guideline's statement on aromatase inhibitors covers men who want to preserve fertility.² A sexual medicine practice that followed 1,708 men on testosterone therapy gave anastrozole to 44 of them, 2.6%, for high estradiol.¹¹ I can't tell you how often clinics that sell testosterone add one, or how many men end up on a second medication because of the hormone. I know a man who takes an anti-anxiety medication he wasn't taking a year ago, after starting a hormone he may not have needed.

If you're a man in an exam room and testosterone comes up, ask whether it's being offered because of a symptom you reported or because of a box on the intake sheet. If the number comes back low, ask whether there was a second morning draw before treatment came up. Neither question takes long.

No fix exists yet. Papaleontiou, the senior author of the Michigan study, said future research should look at whether an intervention is needed at all.⁵ The researchers who counted the problem haven't tested a fix, and until a study does, the second draw depends on a doctor remembering to ask the patient to come back.

I still haven't had the test, but I may get it once my stress levels have returned to normal and I’m still feeling the same. When I do, I'll ask for two mornings, a week apart, before I accept a number as an answer.

References

1. Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744.

2. Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018;200(2):423-432.

3. Pederson PE, Winkelman J, Wong M, Puglisi L, Levine MJ. Assessing Adherence to Guideline-Based Diagnosis and Treatment of Male Hypogonadism in the Age of Direct-to-Consumer Advertising. J Endocr Soc. 2025;9(Suppl 1):bvaf149.1952. Presented at ENDO 2025.

4. Centers for Medicare and Medicaid Services. Clinical Laboratory Fee Schedule, CPT 84403 (Testosterone, Total).

5. Sinha S, Papaleontiou M, et al. Testosterone Therapy in Men May Be Overprescribed, Inconsistent With Clinical Guidelines. Presented at ENDO 2026 (Endocrine Society Annual Meeting), June 2026. University of Michigan Medicine chart review, 200 patients, 2020-2025.

6. Khandwala YS, Raheem OA, Ali MA, Hsieh TC. Variation in Practice Pattern of Male Hypogonadism: A Comparative Analysis of Primary Care, Urology, Endocrinology, and HIV Specialists. Am J Mens Health. 2018. DOI: 10.1177/1557988317743152.

7. Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy. N Engl J Med. 2023;389(2):107-117. (TRAVERSE trial.)

8. US Food and Drug Administration. FDA Issues Class-Wide Labeling Changes for Testosterone Products. February 28, 2025.

9. FDA-approved prescribing information: Depo-Testosterone (testosterone cypionate, Pfizer); Xyosted (testosterone enanthate, 2025 label); Aveed (testosterone undecanoate, Endo, 2025 label); AndroGel (testosterone gel).

10. Pastuszak AW, Gomez LP, Scovell JM, Khera M, Lamb DJ, Lipshultz LI. Comparison of the Effects of Testosterone Gels, Injections, and Pellets on Serum Hormones, Erythrocytosis, Lipids, and Prostate-Specific Antigen. Sex Med. 2015. DOI: 10.1002/sm2.76.

11. Punjani N, Bernie H, Salter C, et al. The Utilization and Impact of Aromatase Inhibitor Therapy in Men With Elevated Estradiol Levels on Testosterone Therapy. Sex Med. 2021;9(4):100378.

12. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315:1096-1099.

13. Travison TG, Vesper HW, Orwoll E, et al. Harmonized Reference Ranges for Circulating Testosterone Levels in Men of Four Cohort Studies in the United States and Europe. J Clin Endocrinol Metab. 2017;102(4):1161.

14. Corona G, Rastrelli G, Monami M, et al. Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis. Eur J Endocrinol. 2013. PMID 23482592.

15. Male Obesity-related Secondary Hypogonadism. PMC6785957.