[INTERVIEW]
Ronda Nelson: An eight-year-old boy completely lost it. He went into an uncontrolled rage, and he ended up biting an adult, and his six-year-old sister had already started puberty. They did scans, they evaluated their home and their histories. Nothing showed up positive, but there was one disturbing clue that came through a little while later that connected and tied it all together, and that’s what we’re gonna talk about today.
Well, that story was fiction, but the risk and the truth behind it was not. It actually came from one of my favorite episodes of a show called House, and the episode was called “Act Your Age.” And what was happening during this particular episode is that the father was secretly, unbeknownst to anyone, applying a non-prescribed testosterone cream.
His daughter ended up developing precocious puberty, so she went into puberty very early, and his son became highly aggressive, and he became very sexualized, and he was rage-y and angry, and they were having problems with him at school. And they realized that both the sister and the brother, the daughter and the son, both had these symptoms because of excessive androgen exposure.
In fact, on the show, they talked about the father’s girlfriend also displaying androgenic effects and passing them along to the people in her world as well. So House, you know, as he is, it’s my favorite show ’cause I learn so much, he eventually traced the whole problem back to this testosterone exposure.
So yes, it was dramatic television for sure, but the mechanism is not something new. It is known to virilize and cause precocious sexual development in children who have been exposed to topical testosterone. In fact, testosterone actually carries an FDA box warning because of the risk.
So I’m not starting with this story because I wanna sensationalize this whole thing. I actually am very opinionated about this. In fact, before I even hit play to record this episode, I broke into a sweat, a hot flash, because I, this just makes me, it makes my skin. I cannot with this topic and this testosterone thing.
So you’re gonna hear me, and I’m telling you, it’s gonna be a little saucy today, so buckle up. We’re gonna talk about this whole testosterone thing. So first, you’ve probably seen the ads that are coming around on social media and Facebook. This low T thing is coming back around, but let’s talk about it first.
I’m not here to tell you that testosterone is a bad hormone. I’m not saying that. That’d be ridiculous, because it is a physiologic normal dominant hormone in men, and it is physiologically normal in women, although at a much lower dose. So testosterone is essential. We can call it an essential hormone. In men, it is produced by the testes, we know this, and we know that it contributes to the development of sperm, et cetera, and male fertility.
Now, there are very, underscore very, very, very few people who really legitimately need testosterone replacement therapy. There are very few, and you may not agree with me, although you might. I don’t know where you are on this fence. My concern is this huge gap between legitimate need for testosterone and the random way that they’re using it to just fix everyone.
Because the truth is that a man’s body does not wake up in the morning and just go, “Gosh, I think today I’m just gonna screw up libido, muscle mass, energy, motivation, drive, and testosterone function, hmm, just for the fun of it. I think that’s what I’m gonna do today. Sounds like a great time. Let’s do that today.” It never happens. The change in the physiology happens because something is not right upstream. Something’s wrong in a pathway.
So low testosterone, if it truly is low, is just a clue. It’s not a diagnosis. The advertisements that you see imply that every single man who has low energy, belly fat, loss of motivation, brain fog, low libido, poor performance, lack of ability to grow muscle, fewer erections, a sense that he’s just lost his edge, and I’m not meaning to make light of legitimate symptoms. My point is that the conclusion everyone is jumping to is, “Oh, you don’t worry there, my friend. You just have low T. Let’s just give it to you. Let’s give you some T, and you can get your life back.” But here is the buster. You ready?
The FDA has actually only approved testosterone replacement products for men with specific types of hypogonadism associated with congenital, acquired, or genetic causes. That’s all that it’s approved for by FDA. That’s it. So things like Klinefelter syndrome, testicular failure, orchiectomy where they’ve had the testicles removed, maybe chemotherapy, radiation, sometimes even HP axis dysfunction in a very clinical sense, not a general sense like we would use it.
That’s all it’s been approved for. There is nowhere in the FDA that it approves testosterone use for fatigue, for brain fog, for belly fat, for low motivation, aging, confidence, muscle mass, blah blah blah. And in addition to that, in April of this year, April of 2026, the FDA put out a new update, and here was their update.
They said to the manufacturers of the testosterone, “Listen, we would like you to prove to us that there might be a new indication for low libido. Could you please give us data on the fact that testosterone might help with low libido?” That’s not an approval. That’s the FDA asking for proof. So how bizarre is it that Facebook out there, I get these ads, and they make me crazy.
The ad shows a round cylinder, and the person on the ad, probably an AI ad, they’re turning the bottom of the cylinder and out through these little holes in the top squirts an amount, and you’re supposed to just take that and rub it right on, and that’s gonna make you feel better. And in the ads it’s for men and women, and spoiler alert, we’re gonna talk about women next week, so I’m gonna get even spicier next week.
But back to the men. The FDA has never approved it for that. How are these ads even getting past Meta? How are they even legally allowed to recommend a prescription hormone for something that has never, ever been cleared for that?
So now, before we start talking about testosterone deficiency per se, let’s talk about the American Endocrine Society. The Endocrine Society says that true hypogonadism is when a man has relevant signs and symptoms, unequivocally low testosterone, very fleeting morning testosterone levels. They’ve done it repeated, and it’ll go up in the morning and then it leaves. And then they will also recommend additional evaluation because those criteria are very general. So the diagnosis is really by multiple points of evaluation.
So my question is, if we’re gonna look at this from an underlying-cause perspective, my question is, okay, what test was collected, and exactly what test did you run? Did you do it on a separate day? Was the patient fasting or non-fasting? What happened the night before, or in the days prior to the test? Was there sleep deprivation? Were they sick? Was there high stress? Did they have food before they took the blood test?
I don’t know. What did they measure? Total testosterone or free testosterone? Did they measure sex hormone binding globulin, which is the primary carrier for testosterone? Did they measure LH and FSH? How about blood sugar and fasting insulin, fasting glucose, A1C? Is there a possibility of exogenous exposure through high levels of androgens or DHEA in bodybuilding products? Those are the questions we need to be asking, because it might not be that there is anything wrong. There might just be a problem within the system.
So a single blood test that shows a single low testosterone does not mean he needs testosterone. I need proof that there truly is a problem, and all those other things have to be evaluated. If you haven’t even looked at LH and FSH, forget it, because LH and FSH are both involved in this whole process in men. Men have both of those hormones. We associate them with women, but men have them both.
So why is the testosterone, if it indeed is, failing to respond? Could it be that he doesn’t really have low testosterone, that he’s got a different upstream problem, but we are giving testosterone anyway? It’s not like a vending machine where you just put the testosterone in and you get virility and libido out. It doesn’t work that way. I wish that it worked that way sometimes, but it doesn’t.
So what happens is the hypothalamus releases GnRH. GnRH signals the pituitary. The pituitary sends LH and FSH. LH stimulates testosterone production in the Leydig cells in the testes. FSH and LH regulate the development of sperm back and forth. Testosterone’s needed for sperm. They feed back to the HP axis, and then the system responds based on that feedback. That’s it. That’s all there is.
So it’s not that we need to go deep into physiology. We just have to understand, well, okay, if it’s low, what does that mean? Does that mean the receptors in the testes aren’t there? Does that mean we have a testicular problem where we need some glandulars or something? Does that mean the HP axis is off? Does that mean there’s too much stress and we have an altered HP axis? I don’t know. We just have to be detectives and start asking. It is not a tube full of testosterone that you should just squirt up and roll on every day, and then you make your kids angry and oversexualized. No, no, no. We are not doing this.
Can you hear my spiciness? Oof, I’m definitely gonna need an adult beverage after this one. Okay, I know you all think I’m an alcoholic. I’m really not, I don’t really drink ever, but I do love it. Anyway, okay, moving on. Little comedic relief right there.
All right, now let’s talk about why this could happen. Certainly stress is a big contributor, because when there’s high stress, that’s going to interfere with GnRH pulsatility from the hypothalamus, affecting the pituitary, which is then going to affect testosterone production. If that HP axis is up on top and the signaling is altered up here with GnRH, FSH, and LH, then of course downstream there are going to be secondary effects.
But does anyone ever ask that question of him? “Do you think your fatigue could be related to stress, related to cortisol?” Does anyone ever even check this? In 2026, a review described stress-associated testosterone suppression as a potentially centrally mediated and reversible reason for testicular failure. Boom. I’ve been waiting my whole life for that. 2026, let me say it again, I’m gonna read it: described a stress-associated testosterone suppression as a potentially mediated and reversible evidence of intrinsic testicular failure.
So how about we just start by managing stress response and upregulating that HPG gonadal axis in men? So it could be that the low testosterone is just an adaptive response. The brain’s getting the information that there aren’t enough resources, and if the stress is too high, the body’s gonna conserve those resources. It’s gonna say, “Pretty sure we’re gonna prioritize survival. We are not gonna worry about the sex handling system,” because that’s kinda not the priority. Surviving is the priority.
Second thing, metabolic. Metabolic issues interfere with the endocrine system every single time, mostly as it has to do with insulin resistance. Metabolic issues also create inflammation. Inflammation can affect the prostate just like it can affect the testes. It alters the HP axis 100%. It alters sex hormone binding globulin. Now we don’t have the carrier proteins anymore to be able to transport the testosterone, we don’t have enough of them. We’ve got more conversion of testosterone to estradiol, and then that feedback to the HPG axis is messed up. So all of that comes back to metabolic signaling.
So when are we having a conversation about him, with him, about what he’s eating and when he’s eating? What is meal timing? Are you getting a protein-forward diet? And if he’s a workout kind of a dude, and if he’s using anything from popular supplement companies (I’ll call it, I used to say GNC, but I probably shouldn’t mention specific names because them and a bunch of others), a lot of those protein powders have DHEA in them. And so the DHEA is also gonna throw a monkey wrench in the whole signaling pathway, and it can convert downstream into the androgens. And then once you get that conversion starting to happen, if he’s under stress, it’s not gonna go to testosterone, it’s gonna go to estradiol. Not always, but it can do that.
If the man is obese, a lot of times they’re a little bit more rotund and they’ve got that visceral belly. Well, then you know there’s inflammation going on. Of course that’s gonna mess with it, but no one wants to talk about that. What do we wanna do? “I just wanna get my manly man-ness working, so I’m just gonna put the cream on. Let’s just do it like a deodorant. Let’s just rub it on, and then I’ll hug my kids while I’m at it and give a little bit to them.” No one’s talking about this.
Obesity is a huge contributor to secondary hypogonadism. Huge contributor. Just getting the weight off can improve testosterone production. So the question is, is the low testosterone because the testes are failing? No. Or because the metabolic environment has shifted and we need to address that.
Another reason is sleep. How many men do you know who don’t sleep well? You know who uses CPAPs the most? Men. Why? Because they’ve got this visceral fat, heavy and thick through the neck and the chest, they can’t breathe, the airways are swollen. You don’t sleep well with a CPAP, you’ve got that thing on your mouth and the noise in the background.
So poor sleep or sleep apnea impacts testosterone 100%. In many men, it will reduce testosterone. It increases cortisol. Poor sleep messes with insulin, causes insulin resistance, fatigue, low libido because you’re not sleeping well, low motivation, and ED can even happen from just poor sleep. They can’t retain muscle mass because they don’t have enough time in the night to recover. There was a small but controlled study that found one week of restricted sleep reduced daytime testosterone in healthy men. One week of low sleep. So think about men who are traveling, time zone hopping, traveling for work. So many people travel for work. That was just one study, a small one, and other studies have had mixed results, but I can’t disagree with sleep being a contributing factor because of its impact on insulin alone and inflammation. So take that for what you will.
Another one is that when you give testosterone, it binds directly to the androgen receptor. When that happens, the next point of conversion is down into DHT, and that happens through the 5-alpha reductase pathway, or it can convert into estradiol through the aromatase enzyme. So depending on the tissue, and depending on the stress, and depending on his insulin, and depending on his sleep, and depending on his diet, all of those things are gonna determine whether that testosterone goes into DHT or converts into estradiol. And DHT is far more potent, has more androgen receptors. Estradiol has a lot of essential functions in male physiology, but you don’t ever, okay, time out, I just thought of something, I’ve never thought of this before, it just occurred to me. Giving a woman testosterone where she doesn’t need very much of it would be equivalent to giving a man estradiol, because that is not his dominant hormone. And on what planet, now I’m getting a hot flash again, on what planet would we give a man estradiol? Never. But we do it to women all the time. I know, women, I’m saving it for next week. I do need to save it for next week. Okay, keep going.
So when you add testosterone, you’re not just moving a number on a blood test. In fact, blood test is probably not the best way to test it anyway. But you’re not just moving a number, you’re adding a substrate to multiple potential pathways. How much of that testosterone goes into DHT? How much goes into estradiol? How does that impact sex hormone binding globulin? What’s happening in the local tissue? Has anybody used saliva? Have they even asked about that? What’s the feedback back to the HP axis?
The testosterone ad makes it look like a man is gonna fill his empty gas tank. He’s just gonna be like, the angels are gonna sing, and the fairy dust is gonna come down from heaven and somehow turn him into a manly, manly man. But that’s crazy. That doesn’t even make sense. If you add that testosterone, it’s like going into the middle of an intersection and changing the traffic lights. Now the traffic is all gonna go discombobulated and go all the different directions. You can’t do that. It doesn’t work.
Hormone availability is not the same as the action of the hormone, because we have receptors, we’ve got genetics, we have sensitivity of the tissue, we’ve got conversion pathways and enzymes that move and convert things around. We’ve got the estradiol and DHT conversions I mentioned. You’ve got different types of conversions for testosterone that happen in the brain, in the muscle, in the skin, in the liver, in the prostate, in reproductive tissue. It’s so different. You can’t look at a serum number and conclusively say what testosterone is doing in every single tissue. So a man can have a hormone present in 10 other tissues, but in the blood it might be low, and so we make the decision, “Oh, you need testosterone.” But how do you even know? That’s why hormones are controlled endocrine, inside. We can’t synthesize them outside the body.
So anything they give, even if it’s a bioidentical, quote, testosterone, or a synthetic testosterone, bad news, bad news, bad news. When you give exogenous testosterone, it does mess with endogenous production. It will, because the negative feedback then impairs the GnRH from the hypothalamus. It’s just what happens. Same with thyroid hormones, same with female hormones. If the testes are supposed to be making testosterone, those Leydig cells are supposed to be making it, and all of a sudden testosterone shows up in the bloodstream, what do the Leydig cells do? They go, “Huh, weird. I thought I was the one that was supposed to be making that testosterone, but somehow, some way, there’s some in here, so guess I don’t need to make it today.” Or tomorrow, or the next day, and pretty soon we have intratesticular levels that are falling. Sperm production can decline. That’s a known fact, and recovery, even after you discontinue the testosterone, takes months and months, and sometimes, in some men, it never recovers. So we can’t be messing around with this testosterone situation. It’s not a vending machine. It’s just not a vending machine.
So in my clinical experience, I have seen over and over hundreds and hundreds of women and men whose respective spouses have been on hormone replacement therapy of some kind. This was 15 years ago, when this kind of became, you know, you could go down to the health food store and buy progesterone. Well, you still can. And what I found in women, they would come to me because they weren’t feeling good, and they were angry and irritated and overwhelmed and had no libido. They didn’t feel good, they just said, “I don’t feel like myself.” This is a woman in her 40s or 50s. And I always did a saliva test. So I would get the saliva test, and her testosterone would be up through the roof. I’m like, “Where are you getting this testosterone?” She’s like, “I don’t know.” So I would ask, “Are you using anything? Is anyone in your house using anything? Using like Axe products or some of these other sensual-type male products?” And come to find out, I had more than one woman say they found out that their husband was using a testosterone product and they didn’t know about it. Now that dysregulates her HP axis, right? No GnRH for her. Now she’s not gonna get the right sex hormones, even though it’s especially worse for her because testosterone is not her dominant hormone. But the same thing goes for men the other way.
When women are on bioidenticals, oral takes a little bit longer, this is my clinical experience, but the creams, like progesterone cream, holy moly, his progesterone will go up like crazy. So the gels and the creams are the worst, and there will be passive transfer back and forth. And it’s not transferred through intercourse, it’s skin-to-skin contact, which is back to my House story initially, that the dad was passing it to his kids just by loving on them and hugging them. That’s what you have, just normal contact. In fact, side note, some of you have been following me for a while, you’ll know this, they first discovered this concept of passive transfer, skin-to-skin contact, in the veterinary world, because they found that these pets had virilization issues. They had hypersexual activity. How many times have you met a dog and all that dog wants to do is get on your leg? Now maybe some dogs, arguably, maybe that’s just how the breed is, I don’t know. But if the owner is using testosterone and you pet the dog, that testosterone gets on the fur skin-to-skin. What do animals do? They lick their fur, and they lick your hands, and they’re up next to you. That’s what they found. This was in the ’70s, they discovered this. So not anything to mess around with.
So again, this is my clinical experience, that I have seen hundreds and hundreds of saliva tests where the woman comes back with high hormones because her husband’s on them, and the husband comes back with high hormones because his wife is on them. So when you use saliva testing, it does fit. There’s a study that shows serum testosterone measurement is very challenging, especially free testosterone, and they recommend, they call it equilibrium dialysis, as the reference method, and I don’t really know about that, that’s not my world. But measuring free testosterone, this is an argument I get all the time, “Well, can’t I just measure free blood?” Nope. It’s actually very challenging. Most circulating testosterone is protein bound. Same if you give it this way, if the man is going to be on this testosterone cream, if it’s not living in the local tissue and being stored in fat cells, then it’s gonna be picked up in the bloodstream and bound to a hormone, albumin or sex hormone binding globulin. That’s it. And so what happens is you bind up the sex hormone binding globulin, and there’s not enough left over or available for other sex hormones. It’s a big deal. But the unbound testosterone can diffuse into saliva, which is why saliva is such a good way to test it. It doesn’t measure the sensitivity in every target tissue, but it is a good indication of what’s happening inside the saliva. You can see what’s happening with testosterone because it’s moving into the saliva.
So neither one is 100% perfect, but I can tell you that blood is definitely not perfect, and I would prefer, if you have to, you want to use both. If you have an unexpectedly high saliva, that doesn’t tell me exactly what’s happening in every single tissue, but it can tell me there could be a pattern. Something is not right. Why do we have all this extra testosterone in the local tissue? It just tells me I need to look further.
So first, here’s what I want you to do. I want you to make sure you get a good history. Ask them, find out what they’re taking, how long they’ve been taking it, ask about their family, ask about aggression in their kids. What’s happening with your wife? Order the right blood labs. Make sure you have sex hormone binding globulin. Make sure you’re ordering albumin. You’re looking at total and free, even though free is a little unreliable, for sure total testosterone. Make sure you’re ordering the right labs. Look at insulin and blood sugar. Look at everything you possibly can that could be related to this. Then you’re gonna want to look at LH and FSH. I like you looking at those on saliva, but you can order them in serum. You could order prolactin if you need to, that can give you some information. You could also look at the testicular pattern, make sure you have a medical diagnosis, that there are no issues, no prostate issues, that kind of thing.
And then ask about the obvious things. Tell me about your diet. Tell me about your stress level. What do you do to manage your stress? Are you overtraining? Are you using any protein powders? Are you wearing a CPAP at night? Look to see if there’s visceral adiposity or inflammation, signs of inflammation, chronic illness even. Are they on opioids or glucocorticoids or other medications that could interfere with HPG signaling or cause a suppression of testosterone? And then look, maybe order DHT, maybe order estradiol, to see if either of those pathways is being preferred in his unique physiology. Look at binding proteins, there’s lots and lots of things to ask. And then, of course, ask about household and partners, and if they are using it, where are you applying it? How long are you staying away from kids? Do you have pets? How are your kids? You want to ask those kinds of questions.
So this whole hormone thing, I know I kind of went on a big physiology deep dive with you here. I get it, I get why it’s appealing. But I think our responsibility is to address the underlying cause. It’s so easy for the patient to say, “I have a problem, I’m looking for a solution. Oh, the guy on Instagram told me that this would solve all my problems.” Because he feels lousy, and he wants help, and he wants his libido back and his strength back and his energy. He wants all that back. I’m fine with that, I get that. But there’s more than what meets the eye going on. And if it’s chronic stress, then fix the stress. Don’t use testosterone, because it can take months for the after effects of that to get reset, if ever. In some cases it doesn’t come back. It’s just not worth it.
What we have to do is educate them. Educate them. Start educating your patients, because this low T thing, it’s kicking up. It is kicking up, and people are talking about it. And I don’t want you to get a patient who comes in and says, “Oh yeah, I started on testosterone,” or, “I talked about GLP a few weeks ago, I just started GLP.” That’s a failure on our part, because we didn’t take the time to educate them. It’s really important to take the time. Let them know, “I understand how you’re feeling, but here are the downsides. Here’s what you need to look for. Here’s why your metabolism might be involved. Here’s why stress might play a factor. Here’s why sleep might play a factor.” Rule out spousal use of any kind of hormone use. The goal is not necessarily, I’ve had men who feel great, and their serum testosterone is low-normal, but they feel great. So just because it’s low doesn’t mean they need it. It means you and I have to go figure out what the underlying problem is.
[CLOSING]
Ronda Nelson: So there you go, that’s my rant. Next week, I’m gonna be back, and we are gonna be talking about women and testosterone, and this one really makes me spicy, so we’re gonna get a little more spicy next week.
Listen, if you love figuring this kind of stuff out, you need to be in Clinical Academy. That’s it, just plain and simple. Go there. What I will teach you is how to move from knowing what to do to knowing what to do next. You have the knowledge, you have the understanding, you just wanna learn how to think about it and then what the protocol is to do next. So for instance, in this case, how do you get a man off of testosterone? Well, I talk about that in Clinical Academy. So go join me over there, go look at the male hormones lesson, and you’ll learn all about it.
Go to rondanelson.com/clinicalacademy to get started. I’ll see you next week. We’re gonna talk about testosterone in women. See you then.
[END]