Low Testosterone

By: Richard D. Levin, MD, FACS

Low T: Do I have it? What can I do about it? Does it matter?

Every day, many men walk into my office asking me if (or telling me) they have “LOW T.”

Most don’t really know what it means, but admit they are really seeing me for fatigue and/or erectile dysfunction. Certainly both can be mediated by low serum testosterone, however there are many contributing factors for each.

First and foremost, I try to obtain a life style history. Sleep disorders (APNEA), prior “supplement use,” or hormone usage, if previously diagnosed, and sexuality/fertility concerns, in addition to overall health related questions, are addressed. Indeed some come in with a lab test waving in my face “look at my low T.” I inspect the data, what labs, were thyroid and binding proteins tested? How about pituitary hormones? What time of day were they drawn? Did he get a good nights sleep?

I address each concern individually and then collectively as part of a bigger health picture.

There is a normal range of serum testosterone, as well as serum binding proteins that adjust free circulating (unbound) testosterone. Low for one man may be just fine for another. Also, there are daily (diurnal) variations as well as exogenous factors that make a single test suboptimal. When there are signs and symptoms of reproducible low testosterone, we then a bigger picture into account. Are there scrotal varicose veins (varicocoels)? A history of prostate carcinoma? A recent viral illness (think mumps)? Usually I wait a few weeks and repeat to get a trend (I have been surprised at the variability and recovery spontaneously). Typically, once a year, I even find a small pituitary tumor as the cause of Low T.

When a patient desires treatment, and I feel it is appropriate, we then discuss the end game/expectations. Is it fertility, ED, fatigue or some combination?

If a young male, concerned about preserving fertility, I use Clomiphene when clinically appropriate.  Varicocoel surgery is also sometimes appropriate and results in no need for any medication, when successful. I try my best to avoid testosterone itself, as it becomes a lifelong dependency and treatment.

Once started on treatment I carefully monitor for side effects with blood work every three months and for results, of course. We pay careful attention of erythrocytosis and rising PSA as the more serious common side effects.  Delivery is adjusted by dose and method.  In the end more than half of patients do not require treatment and half of those that do, have side effects necessitating a change of plans. Those that stay on treatment, really need it for multiple reasons and have great responses.

Final message, if it has stripes it is not necessarily a zebra. We have diagnosed, pituitary tumors (as previously discussed), testicular tumors, thyroid disease, hematological diseases and sleep apnea on otherwise healthy patients who thought they needed testosterone.


Dr. Richard Levin

View posts by Dr. Richard Levin
Dr. Richard Levin is a Urologist with training in: Oncology (NIH/NCI Fellowship trained), Robotic Surgery, Laparoscopic & Endourology, Microsurgery & Infertility, Female Urology, Incontinence, Trauma, Perineal Surgery, Impotence, Urologic Stone Disease (Treatment and prevention) , Infertility, and the use of new technologies (Robotics, Laparoscopy, Cryosurgery, TUMT, Green Light PVP, Contingen, Brachytherapy and ESWL).
He grew up on Long Island, New York, where his family still live. He attended college at Clark University in Worcester, Massachusetts where he obtained a BA and studied Biology and Computer Science.  He attended medical school at the George Washington University, in Washington, D.C.   After completing his second year of surgery, at the Washington Hospital Center, he was an NIH/NCI Fellow in Immunotherapy/Surgical Oncology, with Dr. Steven Rosenberg, at the National Cancer Institute.  He then returned to complete his residency in Urology at the Washington Hospital Center, including special training with a Female Urology Externship at the Columbia Hospital for Women. Since then he has had a private practice in South Florida, and is very busy both surgically and in consultation.
Dr Levin has been a frequent contributor to many cancer conferences and has even been recently published as developing a novel laparoscopic bladder stone procedure.
Men's Health has been a passion of Dr. Levin's, and he has been an advocate of early diagnosis and treatment of cancer and of quality of life concerns, such as impotence and low testosterone and male fertility. He believe patients deserve the best, most modern, technologically advanced and compassionate care, with the least risks.


  1. Zak HinesJune 10, 2015

    It’s interesting to see how so many men think that Low T is a simple “yes I have low T” or “no I don’t”. To read about the multiple different potential causes, even something that seems so insignificant on the surface such as a good night’s sleep, illustrates just how little the average man knows. Additionally, the final point about how men have been diagnosed with pituitary tumors and testicular tumors among other conditions when they believe their symptoms are indicative of “Low T”, shows just how dangerous it is for men to “man up” when it comes to problems with their bodies. Far too many men insist upon “toughing it out” when they feel sick or are in pain that they shoot themselves in the foot when they finally decide to seek treatment. This mindset MUST change.

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