The Testosterone Boom: Who Actually Needs TRT?
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David recently went public about something he'd been managing privately for six months: testosterone replacement therapy, the endpoint of a five-year process that started with a number his previous doctor called normal enough to ignore. In this episode, he sits down with Dr. Treesenberg — a longtime friend of the family, a former infectious disease specialist turned concierge physician, and medical director of a local men's health clinic — to walk through what TRT actually involves, who it's for, and where it gets complicated.
From infectious disease to men's health
Dr. Treesenberg spent over 25 years in hospital-based infectious disease before making the switch to concierge primary care roughly eight and a half years ago. The shift wasn't just about setting — it was about pace and relationship. Infectious disease meant seeing acutely sick patients, often for short windows, with real burnout accumulating over decades of watching very sick people, some of whom didn't recover. Concierge medicine offered something different: time, continuity, and a genuine wellness-and-prevention focus rather than crisis response. Hormone therapy — for men and women both — became a natural extension of that shift.
What actually counts as low testosterone
The number gets debated more than people realize. In the U.S., a total testosterone below 300 is a common threshold; some clinicians use 350; certain endocrinologists set the bar lower still. Dr. Treesenberg's practice rarely treats anyone with a baseline above 500.
But the number alone isn't the whole picture. Free testosterone — the portion not bound to albumin or sex hormone binding globulin, and therefore actually available for the body to use — often matters more than the total. Someone can have an acceptable total testosterone with a genuinely low free testosterone if their sex hormone binding globulin runs high, and there's not much to be done about that specific variable. Checking both, especially at baseline, gives a much clearer picture than either number alone.
Numbers still don't override symptoms. Some men sit at 200 and feel completely fine. Others, like David at 300, feel meaningfully off despite technically falling within a broadly "normal" range — which is exactly the gap that got him dismissed by his previous doctor. The symptoms that actually matter clinically: decreased muscle mass and reduced results from training, decreased libido, metabolic changes, and sometimes brain fog, low mood, or increased anxiety, since testosterone functions as a brain hormone much the way estrogen does in women. Fatigue alone is a weak standalone signal — it's too nonspecific — but combined with other symptoms, it counts.
David's own numbers
David's testosterone tracked from around 700 in his mid-twenties, following significant weight loss, down to roughly 300 over a four-to-five year span — with each annual check showing a lower number and his primary care physician dismissing it because he wasn't hitting textbook deficiency symptoms like erectile dysfunction. By the time he connected with a men's health clinic, his level had dropped to around 290.
He started treatment expecting to test his own skepticism against a possible placebo effect. Within three to four days, he noticed a real, specific difference — more strength in the gym, more energy waking up. Dr. Treesenberg calls this the "five percent" phenomenon: patients who aren't dramatically deficient by clinical standards but are just far enough off their own baseline that correcting it produces a genuine, noticeable improvement in quality of life.
Monitoring: what a responsible protocol actually looks like
Treatment starts conservatively and builds gradually — dosing calibrated to age, weight, and individual response rather than a one-size-fits-all protocol. Follow-up labs happen at six weeks after starting or after any dosing change, checking total and free testosterone, estradiol, PSA, and a complete blood count, since testosterone therapy can raise red blood cell counts and needs monitoring to avoid polycythemia. A full annual panel covers lipids, kidney function, electrolytes, and liver function.
Estradiol monitoring matters more than most patients expect. Testosterone converts to estrogen in the body, and there's a target ratio — roughly 3 to 5 percent estradiol relative to testosterone. Too high, and men can experience worse erectile function and increased moodiness. Too low, and similar symptoms can appear from the other direction. It's a genuine sweet spot, not a "more is better" situation — despite what David describes as a common male instinct to push levels as high as possible. Overshooting doesn't optimize health; it just adds risk without added benefit.
The real side effect profile
The Traverse trial, referenced repeatedly in this conversation, addressed two of the biggest historical fears around TRT — increased prostate cancer risk and worsening cardiovascular disease — and found no meaningful increase in either at standard replacement doses. What the trial did show: a slightly increased risk of blood clots and a slightly increased risk of atrial fibrillation. Patients with a history of recurrent blood clots need real caution. Sleep apnea needs to be treated before starting TRT, since testosterone can worsen it.
Other known effects: hair loss, primarily scalp-related; acne, usually at higher doses; and fertility suppression in younger men, since exogenous testosterone signals the brain to reduce FSH and LH production, which in turn reduces natural sperm production and can shrink testicular size. This effect is generally reversible within three to six months after stopping, though not always — which is exactly why younger men who want children in the future require real caution and, often, alternative approaches.
Delivery methods, and why injections usually win
Injections — intramuscular or subcutaneous, once or twice weekly — remain the most reliable delivery method for consistent levels. Topical creams exist but carry real drawbacks: less predictable absorption, variability introduced when pharmacies change formulations, and a real risk of transferring the medication to a partner through skin contact. Pellet therapy, implanted every four months, produces higher and less controllable peaks — useful for patients with unpredictable schedules like long-haul truckers, but not Dr. Treesenberg's first recommendation. Oral testosterone now exists in better-absorbed formulations than the historically ineffective versions, but it's expensive, requires multiple daily doses, and doesn't produce levels sufficient to meaningfully support muscle mass — useful mainly for fatigue and libido alone.
For men wanting to preserve fertility while addressing genuinely low testosterone, Clomid or HCG can stimulate the body's own FSH/LH production rather than replacing testosterone directly — a real option, though one that doesn't produce the same magnitude of improvement as direct replacement.
Not everyone responds — and that's useful information
Roughly 70% of patients see meaningful symptom improvement. The remainder may have symptoms driven by something else entirely, or may simply have fewer androgen receptors — a variable that can't currently be measured, but that genuinely affects how much benefit any given person gets from the same blood level. A proper trial requires reaching therapeutic levels and sustaining them for two to three months before drawing conclusions.
Lifestyle still matters enormously alongside treatment. Resistance training, adequate protein, and consistent sleep all shape how much benefit a patient actually gets from TRT — the medication supports the physiological foundation, but it doesn't replace the basics.
Peptides: the newer, murkier frontier
The conversation closes on peptides — short chains of amino acids the body produces naturally (insulin and GLP-1 medications are both technically peptides). Growth hormone peptides and BPC-157 are among the most discussed right now, and Dr. Treesenberg draws a clear distinction that applies broadly: there's evidence-based medicine, and there's testimonial medicine. Much of the current peptide enthusiasm sits in the second category — real reported benefits, but built more on animal studies and personal accounts than rigorous human trials.
Growth hormone peptides raise IGF-1 levels, which is generally desirable earlier in life but carries a theoretical, unproven association with malignancy risk as people age, along with a real risk of increased insulin resistance. BPC-157 promotes angiogenesis — genuinely useful for tissue repair, but a mechanism that also plays a role in tumor growth, which is why Dr. Treesenberg recommends particular caution for anyone over 50 and avoids it entirely in anyone with a cancer history. His general approach: use it short-term, cycled, for specific injury recovery — not as an indefinite wellness supplement.
His broader framework for evaluating anything in this testimonial category: what exactly are you treating, what's the actual risk profile, and can you measure whether it's working? Those three questions cut through a lot of social-media-driven hype.
Vitals & Values is the podcast of Concierge Medicine of West Michigan, hosted by Dr. David Roden and Dr. Lara Baatenburg. New episodes available wherever you listen.
