Tired at 45? Check these before you blame testosterone

Quick answer: Testosterone falls slowly with age, and for most men that alone isn't a disease. Treatment makes sense only when you have real symptoms AND repeated morning blood tests that come back low. Rule out sleep, weight, alcohol and mood first, and let your doctor run the process.

What actually happens

Starting somewhere in your thirties or forties, a man's testosterone drifts down. The figure usually cited is about one percent a year. That's a slope, not a cliff. A lot of men reach seventy with levels that are low for a twenty-five-year-old and perfectly adequate for a seventy-year-old.

A smaller group drops far enough, and feels it, that it counts as a medical condition. Doctors call it hypogonadism. It's real, it's treatable, and it's much rarer than the advertising suggests.

The trouble is that the symptoms are the most ordinary complaints in the world. Low energy. A flat mood. Slower recovery from a workout. Thinning muscle and a thickening middle. Trouble concentrating. There are a few more personal ones your doctor will ask about, and you should answer those straight. He's heard it all before.

Now read that list again. It also describes a man who sleeps five hours, drinks four beers a night, sits ten hours a day and carries a lot of stress. Which is most men at forty-five.

Fix the things that lower it first

Several common conditions push testosterone down on their own. Treat them and the number often comes back up without anything else.

• Excess belly fat. Fat tissue converts testosterone into estrogen and feeds the slide. Losing weight in men who are overweight tends to raise testosterone. It's the closest thing to a free prescription.
• Untreated sleep apnea. If you snore, wake up foggy or your wife has noticed you stop breathing at night, get tested. Apnea wrecks sleep, and bad sleep lowers testosterone.
• Short sleep in general. Your body makes much of its testosterone during sleep. Six hours a night is a hormone problem you chose.
• Heavy drinking. It's hard on the testicles and on the liver, and both matter here.
• Opioid painkillers. They can suppress testosterone production. Tell your doctor about any you take.
• Depression and chronic stress. These look like low testosterone from the outside. They can also lower it. Don't skip this one just because it's the one you least want to hear. See Stress Doesn't Stay in Your Head for how it shows up in the body.
• Diabetes and prediabetes. Low testosterone and blood sugar problems travel together. If your numbers are creeping, Your A1C Came Back 5.9. Now What? is worth ten minutes.

Give this a real run. Three months of consistent sleep, ten or fifteen pounds off, and a drink-free week or two will tell you more than any supplement.

How to test it properly

If you've done that and still feel run down, ask your doctor about a blood test. Do it right, because a sloppy test is where most of the confusion starts.

Draw it in the morning. Testosterone peaks early and drops through the day. A reading at 4 p.m. can look low when you're fine. Most guidelines call for a draw before about 10 a.m.

Test twice. A single reading can be a fluke. Illness, a bad night's sleep or a hard workout the day before can all move the number. A diagnosis needs two low morning results on separate days.

Expect more than one number. Your doctor may check total testosterone, sometimes free testosterone, and other hormones that help explain why it's low. Guidelines put the cutoff for "low" somewhere around 300 nanograms per deciliter of total testosterone, but labs differ and your doctor reads the number against how you feel.

Match the number to the symptoms. A low reading with no symptoms generally isn't treated. Symptoms with a normal reading point somewhere else. You need both.

What treatment involves, and what it costs you

If the diagnosis holds, treatment is testosterone replacement: gels, patches, injections or implanted pellets, all prescribed. It can help real deficiency. Men who are truly low often report better energy and mood, along with more muscle and less fat.

It isn't free of trade-offs. Ask your doctor about these before you start:

• Fertility. Replacement can shut down your own sperm production. If you and your wife might want another child, say so first. There are other options.
• Blood thickness. It can raise your red blood cell count, which is why you get regular blood work once you're on it.
• Prostate and heart monitoring. A large 2023 trial, TRAVERSE, followed middle-aged and older men with low testosterone and high heart risk. It found no increase in heart attacks or strokes compared with placebo. It did find more cases of atrial fibrillation, kidney injury and blood clots in the lungs in the treated group. That's reassuring on one front and a reason for care on others. See The Prostate Conversation You Should Have at Fifty for the screening side.
• It's usually long-term. Once you're on replacement, your body makes less of its own. Plan on staying under a doctor's care.

What to skip

Over-the-counter "T boosters." The supplement aisle is full of bottles promising to raise your testosterone. The FDA doesn't review supplements for safety or effectiveness before they're sold, and a label promising manhood in a jar isn't evidence. If it really did what the label says, it would be a drug, and it would need a prescription.

Telehealth clinics that start with the sales pitch. A legitimate one orders two morning labs and asks about your sleep, weight and medications. One that hands you a prescription after a quick online quiz is selling a subscription.

Anabolic steroids. They shut down your own production, sometimes for a long time. That's the opposite of the fix.

This is opinion, but we'll say it: an entire industry has figured out that a man in his forties who feels himself slipping will pay almost anything to get it back. Don't be that customer. Be the one who walks in with a sleep log, a waist measurement and a straight account of what he's drinking.

What to do this month

1. Write down your symptoms and how long you've had them.
2. Get your sleep honest. Seven hours, same bedtime. If you snore hard, ask about a sleep study.
3. Cut the drinking back and start moving. Walking counts. Lifting counts more.
4. Book a checkup. Ask for blood pressure, blood sugar and cholesterol alongside any hormone testing. A low-energy man is often a man with a heart or blood sugar problem nobody has caught. What a Heart Attack Actually Feels Like is worth reading while you're at it.
5. If testosterone testing is warranted, get it done in the morning and repeat it.

Your doctor knows your history, your medications and your family. Use him. The aim isn't to feel twenty-five. It's to be a husband and a father who has the energy to show up fully for the next thirty years.