Should You Start Testosterone? Here's How I Actually Think About It

You're exhausted in a way that sleep doesn't really fix. You're snapping at people you love over things that wouldn't have registered six months ago. You're sore for days after workouts that used to feel manageable, and your drive, in and out of the bedroom, has quietly disappeared. So you finally get your testosterone checked, and the number comes back low.

Does that mean you start TRT immediately? Not necessarily. Does it mean you shouldn't? That's not a simple no either.

I'm Dr. Esra Shermadou, board-certified in Family Medicine and Obesity Medicine, and the founder of Sakinah Health. I see this exact situation regularly, and I'll tell you plainly: low testosterone is rarely a clean, straightforward diagnosis. The symptoms, fatigue, low mood, poor focus, reduced libido, overlap almost perfectly with what chronic stress, disrupted sleep, and poor nutrition can do to a body on their own. That overlap matters, because jumping straight from a low number to a testosterone prescription can mean missing whatever is actually driving the problem.

Your symptoms are the starting point, not your lab number

A number on a page doesn't tell me how you're actually living. What I'm really listening for when we talk:

• Decreased muscle mass, strength, and recovery from training
• Mood changes, irritability, trouble concentrating
• A bigger belly despite real, consistent effort in the gym and kitchen
• Low libido and sexual dysfunction
• Low energy and motivation

Here's what the clinical guidelines actually say: a low number with zero symptoms doesn't require treatment. Testosterone deficiency is defined as a low level plus symptoms, not the number in isolation. But a borderline number with real, lived symptoms? That is absolutely worth a real conversation. I'll tell you plainly: I'm not the doctor who looks at a guy and says "technically in range, so we're done here." Numbers and symptoms get weighed together, specific to your body and your life.

Try this: Which of these symptoms do you actually recognize in yourself, and how long have they been there? What else shifted around the same time: sleep, stress, diet, a difficult stretch at work or home? That overlap is exactly what makes this genuinely hard to diagnose well, and exactly why the conversation matters more than the number alone.

Figure out why it's low

Some causes are reversible, and some aren't. That distinction matters:

• Excess weight, especially visceral fat
• Poor sleep or undiagnosed sleep apnea
• Heavy alcohol use
• Under-eating or overtraining
• Certain medications (please talk to your doctor before stopping anything, because there are usually alternatives worth exploring)
• Pituitary or testicular causes
• Aging: testosterone does naturally decline about 1% a year after 40, but not every man develops symptoms from that gradual shift, so we don't treat every man over 40 automatically

For some men, addressing sleep, chronic stress, and overall metabolic health raises testosterone meaningfully on its own. For others, treatment is genuinely what's needed. And for a lot of men, starting testosterone is actually what gives them the energy and drive to make those lifestyle changes stick in the first place. It's not either/or. Sleep, strength training, adequate protein, and pulling back on alcohol all make any treatment work better, so the goal is to run them in parallel, not treat them as a hoop to clear before we take you seriously.

This week: pick one lever, sleep, training, alcohol, or nutrition, and work on it. Not all four. One.

Get a number you can actually trust

If you're going to make a decision, make it on real data. That means a proper morning testosterone draw, repeated more than once, with free testosterone and SHBG ordered alongside total T, plus a look at your pituitary hormones. I'll tell you plainly: free testosterone is what your body actually uses. Total T alone tells you part of the story, but free testosterone is the fraction that isn't bound up by proteins and unavailable to your tissues, so it needs to be part of your workup, not an afterthought.

Testosterone is part of the plan, not the whole plan

I'll tell you plainly: testosterone therapy is not a prescription that fixes everything on its own. It cannot out-work poor nutrition, disrupted sleep, or a body that isn't being challenged through progressive strength training. The men who see the most meaningful results with TRT are the ones who pair it with the strength, sleep, and nutrition work, because that's where the real benefit lives.

The prescription

This week, start tracking three things: your sleep, your training, and your symptoms. Not because you need to work harder, but because that information tells the real story. Once you have it, the next step is an honest, individualized conversation with a doctor who is looking at the whole picture, not just one number on a lab report taken out of context.

That is exactly what we do at Sakinah Health: real labs, a real exam, a real conversation about what is actually going on in your body and what a plan built around your life looks like. I am based in Dayton, Ohio, with telehealth available across Ohio, Indiana, and Pennsylvania. Book a free consult call when you are ready. The next step is yours.