Care with Roscoe Nelson, MD, board-certified urologist.
Where I trained
Urology covers the adrenal, the parathyroid, the hypothalamus, the pituitary and the gonads, all endocrine organs, and my residency put unusual weight on andrology, the corner of the specialty that deals with male hormones, fertility and sexual function. Testosterone has been part of my work from the start.
I believe in testosterone therapy and I prescribe it. A man who is truly low feels the difference in energy, in training, in mood and in how he holds muscle, and I take that seriously.
Why I will not diagnose you from one number
Most of the testosterone in your blood rides on a carrier protein and cannot enter a cell. A high carrier level can leave a normal-looking total with very little usable hormone behind it. A raised LH means the brain is asking for more than the testicles are making. A total testosterone alone will not show that.
The reference range on your report was built from the men who happened to get tested, and that group has grown heavier and less healthy for decades. Landing inside it means you resemble the average man tested, and the average man tested is not a picture of health. I treat toward where you function well, reading your symptoms, your goals and your panel together.
The panel I order
- Total and free testosterone drawn in the morning, with SHBG
- LH and FSH
- Estradiol, DHEA-S, pregnenolone and prolactin
- Thyroid, iodine, a blood count and PSA
- Alongside it: sleep, weight, alcohol, medications, and whether you may want children
When the first draw is a complete panel, I can often see the whole picture at once. If a man is symptomatic and clearly low, I may not make him wait for a second blood draw.
Fix the reversible causes first
A large share of low testosterone is functional: something correctable has turned the signal down. Body fat is the biggest driver, because fat converts testosterone to estradiol and estradiol quiets the brain's signal. Untreated sleep apnea, opioids, heavy drinking and uncontrolled diabetes do the same. Some men do better raising their own production than taking testosterone, and there are medications that do that. When the reversible causes are addressed and a man is still low with symptoms, I treat him.
Fertility comes before the first prescription
Testosterone from outside quiets the signal to the testicles. Sperm production usually falls, sometimes to zero, and the testicles can shrink. If children are in your future, we talk about that before anything is prescribed, and we use an approach that protects it. If nobody ever asked you, that was a red flag.
Monitoring
Starting testosterone is simple. Monitoring it properly is the real work. I check PSA and hematocrit before treatment and on a schedule during it, repeat the panel, and adjust from the numbers and from how you feel. The largest randomized trial to date, published in 2023 in over five thousand men with cardiac risk, found no increase in major cardiovascular events with monitored therapy. Testosterone therapy has not been shown to cause prostate cancer. No man should be turned away from an evaluation over a fear the data does not support.