Dr. Jamin Brahmbhatt is a urologist and robotic surgeon with Orlando Health and an assistant professor at the University of Central Florida School of Medicine.
You feel unusually tired and sad, and your interest in sex has fallen.
That’s not interesting. If you’re a man, you might think you have low testosterone.
wait a minute. Have we all experienced some or all of these symptoms at once? It is common to feel tired, irritated or unmotivated after a late night out, stressful work, or just a bad night’s sleep.
However, my patients want to eliminate low testosterone as a source, so I often start with a survey called androgen deficiency in the aging men, or Adam’s survey. It will take a little time to see the number of “yes” responses to be collected.
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Are your sexual desires diminished or do you have sex drives?
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Are you lacking energy?
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Has your strength or endurance decreased?
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Have you lost your height?
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Have you noticed that your life’s enjoyment is diminishing?
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Are you sad or in a bad mood?
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Isn’t your erection that strong?
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Have you noticed a recent deterioration in your ability to play sports?
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Are you falling asleep after dinner?
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Have you seen your work performance deteriorate recently?
According to this survey, if you answer “Yes” and “Yes” to Questions 1 or 7, or three or more questions overall may have low testosterone.
Or maybe you won’t. These questions and answers are the beginning and not the end of this journey. These questions may be helpful, but are spacious enough to explain the general living experiences we all face.
As a urologist specializing in male health, patients are often convinced that testosterone is low based solely on these symptoms, but they find that their testosterone levels are completely within range (details at the levels below).
As a field expert, I run to check for testosterone. I just realize that my symptoms are not due to true hormone deficiency, but because of poor sleep habits.
A quick note before diving deeper: I understand that this can be a delicate topic. The information provided here is not true for everyone. Many patients are irritated with my clinic and are looking for a clear answer.
Even in the medical community there is important debate about how to diagnose and manage “low T.” My intention is not to downplay or underestimate concerns, but to provide perspective and education and to help make informed decisions with healthcare providers.
Even for urologists like me, it can be difficult to diagnose low testosterone. That said, according to the latest American Urology Association guidelines, a total testosterone level below 300 ng/dL (nanograms per decilitor) is recommended as a cut-off for the diagnosis of testosterone deficiency.
But here’s a tricky part. Labs don’t always agree with what they consider normal, leading to confusion among patients and healthcare professionals. Take two of the most popular labs in the US (Quest Diagnostics and Labcorp) as an example. The quest lists the normal testosterone range from 250 to 1100 ng/dl, while LabCorp uses 264 to 916 ng/dL. This means that a level of 260 ng/dL could be flagged as “low” in one lab, while another could be flagged as “normal.” Therefore, most American urologists rely on AUA guidelines and keep in mind that all patients are different.
To ensure accuracy, the guidelines recommend checking your testosterone levels twice. This is two separate mornings, ideally from 7am to 10am. That’s because your fluctuating testosterone peaks and is the perfect time to measure your true levels. The first peak occurs in the morning, the second peak (not as high as morning) occurs in the afternoon, with testosterone levels gradually dropping by the end of the day. Lab companies are based on the “normal” reference range, based on the assumption that testosterone testing will be performed at these specific morning hours.
Furthermore, clinical diagnosis of testosterone deficiency relies not only on the number of labs, but also on the presentation of symptoms such as low energy, reduced libido, loss of muscle mass, and changes in mood.
Once you start testosterone therapy, your goal is to raise your testosterone levels to the range of about 450-600 ng/dL. This is considered a “central target” of most laboratory reference ranges. The middle third is a “sweet spot” where most men experience symptom relief or resolution without exceeding levels that can cause unwanted risks or side effects. It can take several months to find an appropriate and safe dose for your patient.
Levels and symptoms are not always sufficient
Adding to our dilemma as a physician, testosterone sensitivity varies from person to person. This variation may be related to genetic factors, according to studies involving testosterone receptor sensitivity. So it is possible that a man with testosterone levels of 400 ng/dL will feel better, while another man with the same level may experience countless symptoms.
Testosterone sensitivity testing is not readily available at present. But the hope is to one day take routine tests that will help you better personalize your testosterone replacement therapy.
Diagnosis and treatment of low testosterone is still a very ongoing work with continuing discussion among experts. However, other medical issues that mimic low testosterone symptoms are easier and supported by powerful research.
Many men whose testosterone lab results are completely normal still experience persistent symptoms. In many cases, these issues are related to lifestyle and other medical factors, not testosterone itself.
In 2025, many health professionals, including myself, became more open to testosterone replacement therapy as new research disproves some of the important risks they previously feared, including concerns about prostate cancer and cardiovascular disease.
Still, testosterone exchanges are not the right choice for anyone, and there may be other medical conditions that mimic the same symptoms that are the main focus of your (and your doctor’s) investigation.
In my own experience, lack of sleep is often the reason behind how tired and frustrating you feel. Sleep is essential for hormone regulation, mood stability and overall health. Chronic sleep deprivation can lead to fatigue, mood swings, low libido and difficulty in focus, according to the National Institutes of Health. These are all symptoms that mimic what is found with low testosterone.
A common cause of sleep deprivation is obstructive sleep apnea. This is a state in which breathing begins to stop repeatedly as you are about to get good night, good night rest. Sleep apnea can reduce hormone balance dysregulation and lower testosterone levels. Continuous positive airway pressure, or the use of CPAP, has been shown to improve sleep quality, improve testosterone, and alleviate symptoms.
I started using the Activity Tracker 24/7. This quickly identified my own sleep problems. Eliminating late afternoon caffeine and changing the evening screen time for reading before bed significantly improved sleep quality, energy levels and overall mood without hormone therapy. My own small changes have led to major improvements.
Stress, lifestyle, hormones
Chronic stress may feel like you’re low in testosterone. Elevated cortisol, the body’s main stress hormone, can temporarily suppress testosterone production and cause the same symptoms as testosterone deficiency, particularly reduced sexual desire and fatigue.
Diet and exercise also play an important role. Studies have shown that testosterone levels in men have been significantly reduced over the last few decades. Experts believe this decrease is closely related to increased obesity rates, chronic stress and an increasingly sedentary lifestyle. Many of my own patients report dramatic improvements in energy, mood and libido simply by losing weight, eating healthier diets, and maintaining physical activity.
Some medical conditions can mimic symptoms caused by low testosterone. Low thyroid or vitamin deficiency (vitamin D or vitamin B12) can cause fatigue, changes in mood, and low libido. Diabetes or heart disease generally causes fatigue and sexual dysfunction. Many patients initially thought they had testosterone deficiency, which has improved significantly after dealing with these (and other) conditions without the need for hormonal treatment.
Another common scenario involves erectile dysfunction. Many patients mistakenly attribute a reduced libido or lack of sexual interest to low testosterone. In most cases, frustration and anxiety about sexual performance led to psychological withdrawal, resulting in reduced sexual desire and confidence.
There are only a few men who have low erectile dysfunction, which is derived from testosterone levels. In these cases, testosterone replacement therapy may be helpful. However, in my personal experience, replacing testosterone alone often leads to more frustration. Men may experience higher sexual desires, but they still have difficulty achieving or maintaining an erection.
Therefore, it is usually better to treat ED directly, using affordable generic drugs like tadalafil and sildenafil to restore sexual confidence and performance. These drugs often cost nearly $40 per pill, and are as affordable as $40 for a three-month supply, providing practical and reliable solutions for most men.
Trouble trends in testosterone testing and treatment
According to 2024 American Urology Association guidelines, the number of men who received testosterone tests and prescriptions has almost tripled in recent years.
The AUA says up to 25% of men who start testosterone therapy have never been tested before they began treatment. Testosterone will not be reconfirmed after treatment is started. Up to a third of men receiving testosterone therapy do not meet the official clinical criteria for testosterone deficiency.
Meanwhile, many men who benefit from testosterone replacement therapy remain untreated due to prolonged concerns among healthcare providers regarding potential prostate cancer or cardiovascular risk. Additionally, men who skip regular screenings or simply feel openly discussing their symptoms are missing out on the treatment and relief they can experience.
Get out of the trap and take control of your health
All this feels like a “chicken or egg” scenario. Will starting testosterone therapy motivate men to exercise more and manage their health better, or should lifestyle and health issues be addressed before considering hormone therapy first? These complexities underscore the importance of personalized conversations between you and your healthcare provider.
In my practice, I always focus on lifestyle first: Are you getting quality sleep? How high is your stress level? Are you physically active? How healthy is your personal relationship? By working on these areas first, many of my patients see significant improvements without falling into testosterone traps.
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