Hormone Therapy: Key Insights Regarding Men’s Health

Understanding men’s health in the context of hormone therapy is essential for those seeking to optimize their health and vitality.

Abstract

In this educational post, I will explore two of the most prevalent and sensitive topics in men’s health: erectile dysfunction (ED) and testosterone deficiency, also known as “Low T”. Drawing from the latest findings presented by leading researchers, I will take you on a journey through the intricate physiology behind these conditions, from the molecular pathways governing erections to the hormonal cascades influencing vitality. We will explore the common causes and risk factors, such as metabolic conditions and lifestyle choices, and discuss comprehensive assessment strategies, including validated questionnaires and essential diagnostic testing. The core of this post will be a detailed examination of the full spectrum of treatment options—from first-line oral medications such as PDE5 inhibitors to advanced therapies including intracavernosal injections, low-intensity shockwave therapy, and penile prostheses. I will also discuss emerging and over-the-counter solutions, providing a balanced perspective on their efficacy and safety. Throughout this discussion, I will explain how our multidisciplinary practice model integrates integrative chiropractic care with functional and conventional medicine to offer a holistic, patient-centered approach to restoring men’s health and quality of life.

Our Integrative and Collaborative Practice Model

At Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, located in El Paso, Texas, we have cultivated a unique and powerful multidisciplinary environment designed to provide comprehensive care. I, Dr. Alex Jimenez, as a Doctor of Chiropractic and a board-certified Family Nurse Practitioner, work in close collaboration with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a board-certified internist with over 40 years of invaluable experience (NPI #1164426749, Texas MD License #J2933) and serves as our Medical Director and Collaborative Physician.

This partnership is fundamental to our philosophy. It allows us to merge the distinct strengths of chiropractic and functional medicine with the diagnostic rigor and medical oversight of internal medicine. For conditions like erectile dysfunction and testosterone deficiency, which are deeply rooted in systemic health, this integrated approach is paramount. My focus on biomechanics, neurologic function, and lifestyle-based functional medicine complements Dr. Cardenas’s expertise in managing complex medical conditions like hypertension, diabetes, and cardiovascular disease—all of which are significant contributors to men’s health issues. With Dr. Cardenas’ medical leadership, we follow guideline-based diagnostics, monitor labs, manage contraindications, and escalate care to endocrinology or urology when appropriate. Together, our team provides a seamless continuum of care, from chiropractic adjustments and rehabilitation to medical management and advanced diagnostic interpretation, ensuring our patients receive a truly holistic and effective treatment plan.

Understanding and Treating Erectile Dysfunction: A Modern Perspective

Many men’s health concerns are sensitive subjects, often shrouded in stigma or misinformation. As a specialist in functional and integrative medicine, my goal is to create a safe space for an in-depth conversation, grounded in evidence and empathy. Conditions like erectile dysfunction (ED) and low testosterone are not just isolated issues; they are often interconnected with overall health, reflecting underlying vascular, neurological, and metabolic states. Today, we’ll demystify these topics, starting with ED.

What is Erectile Dysfunction?

Erectile dysfunction is formally defined as the consistent or recurrent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. The statistics are staggering: it affects approximately 30 million men in the United States alone and is projected to impact over 300 million men globally by 2025.

What’s even more telling is that despite its prevalence, only about 30% of men seek treatment. This reluctance is something I see frequently in my clinical practice. The prevalence is also strongly age-dependent:

• Men under 40: About 10% experience some form of ED.
• Men over 70: This number rises to over 50%.

The financial scope of this issue is also significant. The ED drug market was valued at over $3.6 billion in 2021 and is expected to nearly double by 2028, highlighting the growing demand for effective solutions.

The Complex Physiology of an Erection

To treat ED effectively, we must first understand the intricate biological process of an erection. It is fundamentally a neurovascular event. This means it requires both an intact, responsive nervous system and a competent, healthy vascular system.

Here’s a step-by-step breakdown of the process:

1. Arousal: Sexual stimulation (physical or psychological) activates neural pathways originating in the brain.
2. Nitric Oxide Release: These nerve signals trigger the release of nitric oxide (NO) in the erectile tissues of the penis. NO is a critical neurotransmitter and signaling molecule.
3. Smooth Muscle Relaxation: NO activates an enzyme called guanylate cyclase. This enzyme converts guanosine triphosphate (GTP) into cyclic guanosine monophosphate (cGMP).
4. Vascular Engorgement: The rise in cGMP levels causes the smooth muscles in the walls of the penile arteries and the corpus cavernosum (the spongy erectile chambers) to relax. This relaxation allows a rapid and massive inflow of blood.
5. Erection: The corpus cavernosum fills with blood, expanding and compressing the veins that normally drain blood from the penis. This traps the blood, leading to the rigid state of an erection.

Another enzyme regulates this entire process, phosphodiesterase type 5 (PDE5). PDE5 naturally breaks down cGMP, causing the smooth muscles to contract and the erection to subside. This is a normal and necessary “off switch.” However, in men with ED, this process can be imbalanced.

Key Risk Factors and Causes of Erectile Dysfunction

ED is rarely an isolated problem. It’s often a symptom of a broader systemic issue. In my practice, I emphasize that ED can be an early warning sign of underlying cardiovascular disease.

Major risk factors that significantly impact endothelial function (the health of our blood vessel linings) and hormonal balance include:

• Hypertension (High Blood Pressure): Damages arteries and reduces blood flow.
• Diabetes: Causes both vascular damage (vasculogenic ED) and nerve damage (neurogenic ED).
• Obesity and a sedentary lifestyle contribute to metabolic syndrome, inflammation, and poor vascular health.
• Hyperlipidemia (High Cholesterol): Leads to atherosclerosis (plaque buildup in arteries), narrowing the vessels that supply blood to the penis.
• Tobacco Use: Nicotine is a potent vasoconstrictor, directly impairing blood flow.
• Chronic Alcohol Use: Can lead to nerve damage, hormonal imbalances, and reduced testosterone.

Beyond these metabolic and lifestyle factors, other causes include:

• Psychogenic: Anxiety, depression, stress, and performance concerns can inhibit the neural signals needed for an erection.
• Neurogenic: Conditions like multiple sclerosis (MS), spinal cord injuries, or nerve damage from prostate surgery.
• Medication-Induced: Many common medications can contribute to ED, including certain antidepressants (SSRIs), diuretics, and blood pressure medications.

The Diagnostic Process: A Comprehensive Approach

A thorough evaluation is critical. It’s not just about writing a prescription; it’s about understanding the “why” behind the ED.

1. Detailed History: This includes a full medical, surgical, and sexual history. I often use validated questionnaires like the Sexual Health Inventory for Men (SHIM). This 5-question tool provides a standardized score (1-25) to quantify the severity of ED and serves as an excellent, non-intimidating way to open up the conversation (Cappelleri & Rosen, 2005).
2. Physical Examination: A focused male genitourinary (GU) exam, including a prostate check, is essential. We also assess for signs of vascular or neurologic disease.
3. Diagnostic Lab Testing: A targeted lab panel helps identify underlying medical causes. This should include:

• • Morning Total and Free Testosterone: Testosterone levels are diurnal, peaking in the morning. A random afternoon draw can be misleadingly low.
  • Lipid Panel: To assess for hyperlipidemia.
  • HbA1c: To screen for or monitor diabetes.
  • Thyroid Studies (TSH): Thyroid dysfunction can impact sexual function.
  • Prostate-Specific Antigen (PSA): As an age-appropriate screen for prostate health.

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Signs of Hormonal Imbalances In Men *THIS IS WHY*- Video

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The Spectrum of Treatment Options for ED

Treatment for ED should be a process of shared decision-making between the patient and provider. My role is to educate patients on all available options, discussing the pros, cons, and what to expect from each.

Lifestyle Modification and Integrative Care

This is always Step One. No medication can fully overcome the effects of an unhealthy lifestyle. Key recommendations include:

• Weight Loss and Exercise: Improve insulin sensitivity, reduce inflammation, and boost endothelial function.
• Smoking Cessation: One of the most impactful changes for vascular health.
• Reduced Alcohol Consumption: Moderation is key.
• Stress Management: Techniques like mindfulness, yoga, or biofeedback can help address the psychogenic component.

From an integrative chiropractic perspective, care focuses on optimizing nervous system function. Misalignments in the lumbar spine and pelvis can potentially interfere with the sacral nerve plexus, which plays a role in erectile function. Chiropractic adjustments, combined with targeted rehabilitation exercises, can improve nerve flow, core stability, and pelvic floor function, thereby supporting the neurological component of erections.

Oral Medications: PDE5 Inhibitors

These are the most common first-line medical therapy. Medications like sildenafil (Viagra) and tadalafil (Cialis) work by blocking the PDE5 enzyme. This prevents the breakdown of cGMP, allowing smooth muscle to remain relaxed longer and enhancing blood flow during sexual stimulation.

• Important Counseling Points:

• • These are not “on-demand” erection pills; sexual stimulation is still required.
  • Sildenafil is best taken on an empty stomach about an hour before activity, as a fatty meal can delay its absorption.
  • Tadalafil has a much longer half-life and can be taken as a low daily dose (e.g., 5 mg), promoting more sexual spontaneity. It can also be used “on-demand” at higher doses (10-20 mg).
  • Contraindications: These drugs must NEVER be used with nitrates (like nitroglycerin for chest pain) as this can cause a life-threatening drop in blood pressure (Burnett & Nehra, 2011).

Vacuum Erection Devices (VEDs)

A VED is a non-invasive mechanical option. It consists of a plastic cylinder placed over the penis, a pump (manual or battery-operated) that creates a vacuum to draw blood into the penis, and an elastic constriction ring placed at the base to maintain the erection. While effective for some, many patients find it cumbersome and disruptive to spontaneity.

Urethral Suppositories (MUSE)

This involves inserting a small medicated suppository containing alprostadil (a synthetic prostaglandin) into the urethra. The medication is absorbed through the urethral wall, causing smooth muscle relaxation and increased blood flow. Onset is relatively quick (5-10 minutes), but it is often less effective than injections and can be expensive, as there is no generic available.

Intracavernosal Injections (ICIs)

For men who do not respond to oral medications, ICI therapy is often the next, and highly effective, step. This involves self-injecting a small amount of medication directly into the corpus cavernosum on the side of the penis using a tiny needle.

• Formulations:

• • Alprostadil (Caverject, Edex): The only FDA-approved single-agent injection.
  • Bimix and Trimix: These are more potent, compounded formulations. Bimix typically contains phentolamine and papaverine. Trimix adds alprostadil to that mixture. These are not FDA-approved and must be obtained from a specialty compounding pharmacy. Trimix requires refrigeration.

• Efficacy and Risks: ICIs have a very high success rate, producing a firm erection in minutes. The main risk is priapism, a prolonged erection lasting over four hours, which is a medical emergency. Patients are taught how to manage this and when to seek emergency care.

Low-Intensity Shockwave Therapy (LiST)

This is a promising, non-invasive therapy aimed at addressing the root vascular cause of ED. It uses a device to deliver low-intensity acoustic energy pulses to the penile tissue. The theory is that this creates micro-trauma, which stimulates the body’s natural healing response, promoting neovascularization (the growth of new blood vessels) and improving blood flow. It is still considered investigational by many insurance carriers and is best suited for men with mild to moderate vasculogenic ED (Gruenwald et al., 2009).

Penile Prosthesis (Implant)

A penile implant is the most definitive and permanent solution for ED. It is a surgical procedure with extremely high patient and partner satisfaction rates (often >90%). The most common device is a three-piece inflatable prosthesis, which consists of:

1. A pair of cylinders placed inside the corpus cavernosum.
2. A fluid reservoir placed in the abdomen.
3. A small pump placed discreetly in the scrotum.

Squeezing the pump moves fluid from the reservoir into the cylinders, creating a firm, natural-feeling erection. Pressing a deflation button on the pump returns the fluid to the reservoir. While it is a surgical procedure with associated risks (e.g., infection, mechanical failure), it provides a reliable, on-demand, and completely concealable solution for men who have failed other therapies.

Online Platforms and Over-the-Counter Options

The rise of telehealth platforms like Hims & Hers has dramatically increased access to ED treatment. They connect patients with licensed providers who can prescribe ED medications, often in unique compounded formulations such as chewable tablets or mints. While convenient, it’s crucial to remember that these compounded drugs are not FDA-approved for safety and efficacy in the same way as commercially manufactured drugs.

A newer over-the-counter option is Eroxon, a topical gel. It works via a physical evaporative action, creating a rapid cooling-then-warming sensation on the glans of the penis. This stimulates nerve endings, promoting blood flow. It does not contain a pharmaceutical drug. While clinically tested, user reviews are mixed, and its efficacy is generally considered modest compared to prescription therapies.

Deconstructing Testosterone Deficiency: Evidence-Based Support for Men’s Health

Let’s now transition to another cornerstone of men’s health: testosterone deficiency, or hypogonadism. You’ve undoubtedly seen the commercials promising to help you “recapture your youth,” “maximize your strength,” and “spice up your love life.” While there’s a lot of marketing hype, testosterone deficiency is a real and treatable medical condition that significantly impacts a man’s quality of life.

In my practice, I find that while men may be hesitant to discuss ED, they are often very concerned about their energy levels, muscle mass, and libido—all areas profoundly influenced by testosterone. Men frequently ask how to recapture how they felt—and performed—in their twenties and thirties. They want strength, stamina, sharper focus, healthier libido, and reliable energy. As a clinician, I embrace that goal, but I do it with rigor: thorough diagnostics, evidence-based therapies, and integrated care that addresses root causes. Here, I walk you through the physiology of hypogonadism, structured testing, treatment choices, precautions, and how our integrative care team supports the whole person.

Understanding Hypogonadism: Definitions, Prevalence, and Physiology

Hypogonadism is a clinical syndrome where the testes fail to produce adequate physiological concentrations of testosterone and/or sperm. Testosterone deficiency is generally confirmed by at least two separate morning total testosterone measurements less than 300 ng/dL in the presence of compatible symptoms, such as decreased libido, erectile dysfunction, fatigue, and loss of muscle mass (Mulhall et al., 2018; Wu et al., 2010).

Testosterone falls gradually with age, about 1–2% per year. The prevalence of deficiency increases with age, with significant proportions of men in their 50s to 80s exhibiting low biochemical levels and symptoms (Wu et al., 2010). However, modern analyses suggest a substantial fraction of men using testosterone therapies do not meet strict diagnostic criteria or were not adequately tested before initiation (Layton et al., 2014). This underscores the need for careful, guideline-based evaluation.

Key Physiology: Why Testosterone Matters

• Anabolic Signaling: Testosterone supports protein synthesis, muscle hypertrophy, and repair through androgen receptor-mediated transcription in skeletal muscle. It influences satellite cell activity, myonuclear accretion, and neuromuscular efficiency.
• Vascular and Metabolic Effects: Testosterone modulates endothelial nitric oxide production, insulin sensitivity, adipocyte differentiation, and visceral fat deposition. Low testosterone is associated with increased fat mass, decreased lean mass, and higher cardiometabolic risk (Kelly & Jones, 2015).
• Neurobehavioral Components: Testosterone contributes to motivation, energy, and mood via central nervous system actions, interacting with dopaminergic pathways and neuroendocrine stress axes.

Primary and Secondary Causes of Low Testosterone

• Primary Hypogonadism: This indicates direct testicular failure due to aging, genetic disorders, autoimmune damage, chemotherapy, radiation, or orchiectomy.
• Secondary Hypogonadism: This results from hypothalamic-pituitary suppression due to obesity, diabetes, obstructive sleep apnea (OSA), systemic inflammation, and certain medications. OSA and obesity are especially important in modern practice; both reduce nocturnal gonadotropin pulses and impair luteinizing hormone (LH)-driven testicular androgen production (Morselli et al., 2014).
• Modifiable Contributors: Excess alcohol, opioids, glucocorticoids, and anabolic steroid misuse can suppress endogenous testosterone.

Diagnostic Strategy: A Stepwise, Safety-Focused Algorithm

• Morning Total Testosterone: I always obtain a morning sample (usually 7–10 AM) when testosterone is highest. The reason for this is the circadian rhythm of hormone release. If the result is less than 300 ng/dL, I repeat the test on a separate morning to confirm the diagnosis (Mulhall et al., 2018). An afternoon test often underestimates testosterone and can lead to a false diagnosis.
• Adjunct Labs:

• • LH and FSH: These hormones help distinguish primary (high LH/FSH) from secondary (low/normal LH/FSH) hypogonadism, which is crucial for targeting therapy.
  • Prolactin: Elevated levels (>25 ng/mL) may indicate pituitary pathology. I consider an endocrinology referral and a pituitary MRI when clinically indicated (Bhasin et al., 2018).
  • Hematocrit/Complete Blood Count: This establishes a baseline and allows us to monitor for erythrocytosis, a potential side effect of therapy.
  • PSA: We screen in men at risk when considering testosterone therapy.

• Consider Free Testosterone: In cases with borderline total testosterone or altered sex hormone-binding globulin (SHBG), calculating free testosterone can improve diagnostic clarity (Bhasin et al., 2018).
• Evaluate Comorbidities: We assess for hypertension, hyperlipidemia, OSA, obesity, diabetes, and thyroid dysfunction, as they can mimic or exacerbate low testosterone symptoms.

This algorithm provides essential safety gatekeeping. Monitoring hematocrit, PSA, and prolactin protects patients from unrecognized risks like polycythemia, occult prostate disease, or pituitary adenomas.

Case Study: A 56-Year-Old Man with Low Testosterone Symptoms

To illustrate this process, I encountered a 56-year-old male with hypertension, hyperlipidemia, obesity, and obstructive sleep apnea. He reported fatigue, reduced endurance, lower libido, weight gain, and mild erectile dysfunction. His primary care provider had measured his total testosterone at 150 ng/dL in the afternoon. He had a CPAP machine but was not using it consistently.

My plan was as follows:

1. Reinforce CPAP adherence for at least three months and reassess symptoms. Treating OSA can significantly improve morning testosterone and sexual function (Hoyos et al., 2012).
2. Order two separate morning testosterone tests with LH, FSH, prolactin, hematocrit, and PSA. This validates the diagnosis, clarifies the cause, and establishes safety baselines.
3. Initiate lifestyle optimization: structured exercise, weight reduction, alcohol moderation, sleep hygiene, and cardiometabolic dietary strategies.
4. Consider a PDE5 inhibitor for his erectile function while we address the root causes.
5. If confirmed testosterone deficiency persists after optimizing his OSA treatment, discuss testosterone replacement therapy (TRT) versus a selective estrogen receptor modulator (SERM) like clomiphene, depending on his fertility goals and preference.

Therapeutic Options: Formulations, Pros, and Cons

Intramuscular Testosterone (Cypionate, Enanthate, Undecanoate)

• Why choose IM: It offers reliable delivery, broad insurance coverage, and robust symptom improvement. Dosing often ranges from 75–100 mg weekly or 150–200 mg every two weeks for cypionate.
• Peaks and Valleys: IM injections produce supraphysiologic peaks shortly after dosing and troughs before the next dose. Some patients feel these fluctuations; weekly micro-dosing can smooth this variability.
• Practical Handling: I instruct patients to store it at room temperature, inspect the vial for clarity, and protect it from light.

Transdermal Gels (e.g., AndroGel, Fortesta)

• Why choose gels: They provide steadier daily testosterone exposure with fewer peaks and troughs, which is useful for patients sensitive to IM fluctuations.
• Application: Gels are applied to the shoulders, upper arms, or thighs. I counsel patients to avoid the genitals and apply deodorant first if needed.
• Safety: There is a black box warning for secondary exposure. It is crucial to prevent transfer to partners or children via strict application and covering protocols.

Pellet Therapy (Testopel)

• Why choose pellets: The long-acting delivery, every 3–4 months, can be convenient and may maintain stable levels for some individuals.
• Procedure: This involves a subdermal implantation in the buttocks fat layer using aseptic technique. I typically start with approximately six pellets (75 mg each) and titrate based on clinical response.

Oral and Intranasal Testosterone

• Oral options (e.g., testosterone undecanoate capsules): These are absorbed via the lymphatics, circumventing first-pass liver metabolism. They are often expensive and may carry warnings for blood pressure and cardiovascular events, so I use them selectively.
• Intranasal formulations: These can cause nasal irritation and an altered sense of smell, and they carry a risk of transfer. They are rarely preferred in my practice due to adherence and tolerability issues.

Selective Estrogen Receptor Modulators (e.g., Clomiphene)

• Why choose clomiphene: This is an excellent option for younger men who desire to preserve fertility or for those averse to exogenous testosterone. Clomiphene blocks estrogen feedback in the brain, thereby increasing LH and FSH and stimulating the body’s own testosterone and sperm production (Taylor & Levine, 2010).
• Dosing: I commonly start with 25 mg three days per week (e.g., Monday/Wednesday/Friday) and titrate up to 50 mg three days per week based on labs and symptoms.

Foundational Support: Lifestyle, Functional Medicine, and Chiropractic Care

Lifestyle and Functional Medicine

• Weight Loss and Insulin Sensitivity: Reducing visceral fat and improving insulin sensitivity can increase SHBG and normalize hypothalamic-pituitary signaling, supporting natural testosterone recovery (Kelly & Jones, 2015).
• Anti-Inflammatory Nutrition: I recommend a diet emphasizing whole foods, fiber, omega-3s, and polyphenols to reduce systemic inflammation and support endothelial function.
• Micronutrients: Adequate zinc and selenium are important for testicular function, though dietary changes alone rarely produce large testosterone increases. I treat confirmed deficiencies rather than recommending supplements based on myths (Prasad, 2014).
• Alcohol and Tobacco: Reducing alcohol and eliminating tobacco improve vascular and endocrine function, enhancing sexual health.

Chiropractic Care: Biomechanics, Autonomic Balance, and Endocrine Synergy

This is where my integrative approach comes into full focus.

• Pain and Endocrine Stress: Chronic musculoskeletal pain elevates sympathetic (“fight or flight”) output and cortisol, which can suppress the release of hormones that stimulate testosterone production. By correcting spinal and joint mechanics and reducing pain signals, chiropractic care helps downshift this sympathetic overdrive and improves sleep quality—both crucial for nocturnal testosterone production.
• Movement as Medicine: Targeted mobility, graded strength training, and postural correction facilitate anabolic signaling. My clinical observations across thousands of visits show that restoring thoracic mobility, pelvic stability, and diaphragmatic breathing improves exercise adherence, reduces perceived fatigue, and enhances sexual health outcomes.
• Personalized Rehab Plans: We combine manual therapy with progressive loading and neuromuscular re-education. In our personal injury practice, we see how resolving pain and restoring kinetic chain integrity reduces the body’s stress load, enabling hormone normalization and a faster return to exercise.

Medical Oversight and Monitoring: Keeping Care Safe

Under Dr. Cardenas’s medical direction, we adhere to strict monitoring protocols.

• Hematocrit and Erythrocytosis: Testosterone can increase red blood cell mass. I check hematocrit at baseline, at 9–12 weeks after starting TRT, and then every 6–12 months. I consider intervention (dose adjustments, phlebotomy) when hematocrit approaches 52–54% (Bhasin et al., 2018).
• PSA and Prostate Health: While TRT does not cause prostate cancer, it can modestly increase PSA. We monitor regularly and make a shared decision for urologic referral if concerning trends arise (Mulhall et al., 2018).
• Blood Pressure and Lipids: We track BP and lipid profiles, as Dr. Cardenas’ internal medicine expertise ensures comprehensive cardiovascular risk management.
• Contraindications: We avoid TRT in men with untreated or metastatic prostate/breast cancer, severe untreated OSA, hematocrit >50%, severe lower urinary tract symptoms, poorly controlled heart failure, a recent heart attack or stroke, or active fertility goals.

Clinical Observations: What I See in Practice

• Patients who correct OSA and lose visceral fat often experience better morning energy, libido, and training recovery even before starting hormone therapy.
• Those who prefer transdermal gel appreciate smoother day-to-day performance; IM users often switch to weekly dosing to reduce fluctuations.
• Carefully titrated clomiphene can be a useful bridge in younger men wanting to preserve fertility while addressing symptomatic low testosterone.
• When chiropractic care optimizes rib cage and diaphragm mechanics, patients report improved sleep quality, reduced snoring, and greater morning alertness—which is synergistic with CPAP adherence.

Action Steps for Readers

If you have symptoms such as decreased libido, fatigue, reduced exercise performance, weight gain, or mild ED, consider:

• Getting two morning total testosterone tests with LH, FSH, prolactin, hematocrit, and PSA.
• A sleep evaluation and strict OSA management if applicable.
• A cardiometabolic plan addressing diet, exercise, weight loss, and alcohol moderation.
• A discussion of TRT versus clomiphene depending on your fertility goals and risk profile.
• Integrative chiropractic and rehab to relieve pain and optimize movement for training success.

References

• Bhasin, S., Brito, J. P., Cunningham, G. R., Hayes, F. J., Hodis, H. N., Matsumoto, A. M., Snyder, P. J., Swerdloff, R. S., Vigen, R., & Yalamanchi, S. (2018). Testosterone therapy in men with hypogonadism: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 103(5), 1715–1744.
• Burnett, A. L., & Nehra, A. (2011). Diagnosis and treatment of erectile dysfunction. American Urological Association Education and Research, Inc.
• Cappelleri, J. C., & Rosen, R. C. (2005). The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. International Journal of Impotence Research, 17(1), 1–10.
• Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J., & McKinlay, J. B. (1994). Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. Journal of Urology, 151(1), 54–61.
• Gruenwald, I., Appel, B., & Vardi, Y. (2009). Low-intensity extracorporeal shock wave therapy—a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitors. The Journal of Sexual Medicine, 6(9), 2596–2604.
• Hatzimouratidis, K., Giuliano, F., Moncada, I., Muneer, A., Salonia, A., & Verze, P. (Eds.). (2022). EAU Guidelines on Sexual and Reproductive Health. European Association of Urology.
• Hoyos, C. M., Killick, R., Yee, B. J., Grunstein, R. R., & Liu, P. Y. (2012). Obstructive sleep apnea and testosterone deficiency. Journal of Clinical Endocrinology & Metabolism, 97(7), 2312–2319.
• Kelly, D. M., & Jones, T. H. (2015). Endogenous testosterone and mortality: A systematic review and meta-analysis. International Journal of Impotence Research, 27(4), 174–186.
• Layton, J. B., Li, D., Meier, C. R., Sharpless, J. L., Stürmer, T., Jick, S. S., & Brookhart, M. A. (2014). Trends in testosterone prescribing in the United States. JAMA Internal Medicine, 174(10), 1569–1572.
• Morselli, E., Santos, R. S., & de Assis, A. M. (2014). Aging, obesity, and the hypothalamo-pituitary-gonadal axis. Hormone Molecular Biology and Clinical Investigation, 17(2), 73–88.
• Mulhall, J. P., Trost, L. W., Brannigan, R. E., Kurtz, E. G., Redmon, J. B., Chiles, K. A., … & Bhasin, S. (2018). Evaluation and management of testosterone deficiency: AUA guideline. American Urological Association.
• Prasad, A. S. (2014). Zinc in human health: effect of zinc on immune cells. Molecular Medicine, 20(1), 1–5.
• Taylor, F., & Levine, L. (2010). Clomiphene citrate for the treatment of hypogonadism. International Journal of Urology, 17(2), 186–189.
• Wu, F. C., Tajar, A., Beynon, J. M., Pye, S. R., Silman, A. J., Finn, J. D., … & the EMAS Group. (2010). Identification of late-onset hypogonadism in middle-aged and older men. The New England Journal of Medicine, 363(2), 123–135.

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